Once you’ve set an initial appointment with our office, please either download and complete all 5 pages, or click the links under Complete Online, and fill out the documents online prior to your visit. Completing and signing the documents online is HIPPA compliant and secure.
If you prefer to download and print them, be sure to bring these completed forms to your appointment and please arrive 30 minutes prior to your scheduled appointment time.
PLEASE NOTE: ALL OF THE FORMS WITH * ON THE TITLE ARE REQUIRED TO BE COMPLETED
We also request that you bring any relevant medical records with you, such as hospital records, previous allergy testing, radiology and/or laboratory results.
AN IMPORTANT NOTICE FROM THE CENTERS FOR MEDICAID AND MEDICARE
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.
DOWNLOAD, COMPLETE AND BRING WITH YOU:
COMPLETE AND SIGN ONLINE: