Patient Forms

Patient Forms

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)
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. Autorización De HIPAA Para Divulgar Información Del Paciente
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
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)
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