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Patient Forms

Patient Registration (PDF) - All patients should fill out this form to register with us.

Consent for Treatment (PDF) - All patients must provide their consent for treatment. Autorización y Consentimiento Para el Tratamiento.

Patient Record of Disclosures (PDF) - Gives patients the ability to request the uses and disclosures of their protected health information (PHI).

Release of Patient Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. HIPAA Autorización para la divulgación de información de salud del paciente.

Notice of Privacy Practices (PDF) - This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

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. Política Financiera (PDF)

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. Aviso de prácticas de privacidad (PDF)

HIPAA Privacy Notice