Patient Forms

Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.

Our myPrivia Patient Portal has a new, modern look and improved navigation to help patients access their health information or message their provider.

Experience an enhanced, easy-to-use online Epion self-check-in process that captures and updates your insurance card images, medication changes, and payments. The improved Bill-Pay experience allows you to view a detailed summary of your amount due and pay with the convenience of a saved credit card.

If you need assistance with using the portal, please reach out to (888) 774-8428.


Patient Forms

Authorization for Release of Medical Information (PDF) – Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente

Authorization and Consent for Treatment (PDF) – All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts (PDF) – Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Virtual Visit Policy (PDF) – This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

My Gene History  – Capturing a personal and family history of cancer is something we believe is very important to your management care plan. We do this before all appointments. This survey takes 5 minutes to complete. Genetic testing is also available in the office.

Office Policies

Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)

Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)

HIPAA Privacy Notice