Patients are asked to update their contact and insurance information on each visit. If you would like to complete the Pateint Information Form (Page 1 & Page 2) prior to your visit, please click the link and download the form. Depending on your browser and its settings, the Patient Information Form (PDF form, see the **Notes below) may be automatically downloaded or it may open within the browser. If the Patient Information Form opens within the browser and cannot be filled out, save (download) the form to your hard drive and then open it with a PDF reader program. Once you have opened the file a the PDF reader program (e.g., Adobe Reader or Preview on a Mac) you should be able to type in your information, print it and bring it with you.
If your insurance coverage includes Medicare, there is an additional PQRS Form (Physician Quality Reporting System) that you need to fill out (Medicare requires us to ask these questions). The PQRS Form is a PDF file that you will have to first print and then circle / write in your answers.
** Note that the Patient Information Form will allow you to type more text than will be printed. If the text box develops a vertical scroll bar you have entered more information than the form can print. In this case please provide the additional information by creating a separate text document or writing it down when you get here. You can also just print out your own list if you maintain one on your computer.
** The Patient Information Form also includes demographics questions (race, ethnicity and preferred language). These questions and the choices in the drop down menu are from the Centers for Medicare & Medicaid Services.
You will need to have a PDF reader installed on your computer.
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If you would like to provide comments or suggestions to improve the usability of this form, please fill out the Feedback Form.