Patient Forms and Office Policies

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.

 

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.

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.

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

Office Policy (PDF) – Describes new office policies as they relate to COVID protocols, cash payments, using our patient portal and our Kindness Policy.

Epion Check In Procedure – This flyer introduces you to our new smartphone check in procedure for all patient visits prior to your appointment – both new and returning patients. If you don’t have access to a smartphone, you can forward the link to your desktop for completion.

myPrivia Mobile App – Download “myPrivia” from the App Store or Google Play. With myPrivia you can start or join a virtual visit, securely manage your care, make an appointment and visit the 24/7 Virtual Clinic. For assistance installing or using myPrivia, please call (888) 774-8428.