Patient Form

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.

The previous PQRS form is no longer needed, but there are more questions that we have to ask. That form is currently under revision. When it is finalized we will put it on this site, but until then we will need you to fill this one out in the office. We apologize for the inconvenience.

** 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.

 


 

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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.