Patient Forms

REGISTRATION FORMS

Patient Information
English    Spanish

Patient Cancellation and No-Show Agreement
English    Spanish

Federal Support Information
Bilingual

PEDIATRIC FORMS

Consent to Treat a Minor/Child
Bilingual

PATIENT RIGHTS AND PRIVACY FORMS

Patient Rights & Responsibilities
English    Spanish

Patient’s Right to File Complaints and Grievances
English    Spanish

Patient Complaint or Grievance Form
English    Spanish

Notice of Privacy Practices
English    Spanish

Consent to Disclose Health Information Verbally
English    Spanish

Authorization to Disclose Protected Health Information
English   Spanish

FINANCIAL FORMS

Patient Financial Agreement
English    Spanish

Application for Discount
English    Spanish

SLIDING FEE DISCOUNT SCHEDULES

Sliding Fee Discount Schedule (Medical & Dental)
English    Spanish

Sliding Fee Discount Schedule (Behavioral Health Only)
English    Spanish

MEDICARE FORMS

Checklist for your Medicare Annual Wellness Visit (AWV)
English Spanish

Medicare Initial Preventive Physical Exam (IPPE)
English Spanish

Medicare Part B Coverage Reference List
English Spanish