New Patient Info & Forms

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For your convenience, you may complete new patient forms in advance. Please select and print from the options below, fill them out completely and bring them with you to your appointment.

If you are not able to complete the forms before your visit, please allow at least 30 minutes for completion in the office before you see the doctor.

Patient forms are currently being revised.  Please check back soon!

Adult New Patient – For adults (age 16+) with a new patient appointment
(English Version) |  (Spanish Version)

Pediatric New Patient –  For children (age less than 16) with a new patient appointment
(English Version) |  (Spanish Version)

Physical Evaluation Form
(English Version) |  (Spanish Version)

Acknowledgement of Receipt and Notice of Privacy Practices (HIPAA) – Describes how medical information about you may be used and disclosed and how you can access this information. HIPAA requires all patients to complete this form.
(English Version) |  (Spanish Version)   

Medical Release – Form authorizing healthcare provider to release your medical information to Providence Medical Partners
(English Version) |  (Spanish Version)

Financial Policy – Explains Providence Medical Partners’ payment of services
(English Version) |  (Spanish Version)

Red Flags Payment Permission Form – Form authorizing a patient the use of Medical Flex card, personal credit card, or personal check to pay for the services that they receive at Providence Medical Partners

Consent for Treatment – Form giving Providence Medical Partners consent to give you treatment
ADULTS (English Version) | PEDIATRICS (English Version)
ADULTS (Spanish Version) | PEDIATRICS (Spanish Version)

Request for Correction / Amendment to Record – Allows you to request a correction / amendment to your medical record.  (English Version) |  (Spanish Version)

Record Release and Authorization to Use and Disclose Health Info
(English Version) |  
(Spanish Version)

Pre-participation Physical Evaluation Form – This form is for Sports Physicals

Immunization Registry Consent Form – Allows schools to verify records.  (English Version) |  (Spanish Version)

Patient History –  (English Version) |  (Spanish Version)

Consent to Contact  –  (English Version) |  (Spanish Version)

Please bring all medications you are currently taking to your appointment.

Personal Identification Needed

Be sure to have your valid driver license and insurance card(s) with you.

Payment Policy

Due to recent changes in healthcare plans, some patients have questions regarding patient and insurance responsibility for services rendered. Our rates are representative of the usual and customary charges for our area. Please review our payment policy information below. You will be provided with a copy of this information to read and sign at your office visit. Please let us know if you have any questions or concerns.

Insurance

We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, present your current card at your office visit so that we may verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

Co-payments and deductibles

All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment and/or deductible at each visit.

Payments can be made in the form of cash, personal check or credit card. We accept MasterCard, Visa, Discover and American Express.

Coverage changes

If your insurance changes, please notify us before or on your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay within 30 days, you will be responsible for the balance.