Patient Forms

The following forms are provided to improve the efficiency of our office and to allow you, the patient, ample time to read, understand, and complete them.

The Patient Information (1 page) and Medical History (2 pages) forms will need to be completed prior to your appointment. They will include personal information which requires your signature, as well as your current health condition and past medical history.

Your signature is required on the Financial Policy (1 page) form. It explains how we receive payment for our services. We make every effort to help you receive your maximum allowable benefits by filing claims with your insurance or with the government.

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you notice about our privacy practices, our legal duties, and your rights concerning your health information. Our Notice of Privacy Practices (2 pages) contains this information and includes an Acknowledgement of Receipt of Notice of Privacy Practices (1 page) form and a Consent for Use and Disclosure of Health Information (1 page) form which both require your signature.

Our New Patient PDF Document includes the above forms which are pertinent to all new patients. We recommend that you download, print, and complete them prior to your office visit. If you choose not to, you may complete them in our office prior to your appointment.

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Our Medical Records Release form may be utilized when you need to authorize the release of your protected health information to another health care provider.

The Referring Physician Request For Consult form will be completed by your physician when a consult with Dr. Robinson is requested.