PATIENT FORMS AND DOCUMENTS

Downloads

The following downloads are part of each patient’s medical file and must be updated annually or as information changes.

Speed up you Visit

By downloading and completing the forms below prior to your visit, you can drastically reduce the time of your visit.

Laptop screen stethoscope in doctors hand

Documents and Forms

  1. All patients must have all “New Patient” forms completed and in their patient file.
  2. All patients must have completed “history” files in their patient files
  3. Patients who have Medicare, Medicaid, and Insurance coverage must have completed “Screening” files in their patient file.
  4. School and Athletic Physical forms are to be completed by both the student/athlete and their parent/guardian prior to examination.  Copies are kept on file.
  5. Some forms will require annual or semi-annual revisions to meet insurance or treatment plan requirements.
 
NEW Patient and Annual Update Forms

Patient Introduction Letter

Intake History Form

Controlled Medication Form 2021

Financial Policy Form 2021

General Consent Form 2021

HIPAA Privacy Rights 2021

Notice of Privacy Practices 2021

Patient Rights and Responsibilities 2021

Release of Protected Health Information 2021

Health Screening Questionnaires (required by Medicare and Most Insurances)

Health Status Questionnaire

Alcohol Screening Questionnaire

DAST-10 Drug Abuse Screening

GAD-7 (Generalized Anxiety Disorder Screening)

Tobacco Cessation Counseling

PHQ-9 Questionnaire

Fall Risk Assessment Tool

Pre-Participation /Athletic/School Physical Forms

UIL PrePhysFormRvsd1-19

Athletic Physical Emergency Contact Form

Concussion Awareness and Policy

Heat and Humidity Awareness

If you have any questions, please contact us.