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Patient Forms

Please turn in any patient forms directly to the patient portal, Please call the office at 897-6140 to be invited to the portal.

Authorization for Release of Medical Information (PDF) — Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.

Authorization and Consent for Treatment (PDF) — All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts (PDF) — Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Virtual Visit Policy (PDF) — This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Office Policies

Financial Policy (PDF) — This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.

Notice of Privacy Practices (PDF) — Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.

HIPAA Privacy Notice