Patient Forms
Online Forms
Download Patient Forms
To view our forms, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com. You may bring your completed forms to the office at the time of your visit or mail/fax them to us once they are completed.
These forms are provided to help make your visit to our office as convenient for you as possible. If it is your first visit, please be sure to complete the Welcome/Patient Information Form and the General Authorization to Disclose Protected Health Information form.
Welcome/Patient Information Form
Please complete this form in its entirety before your first visit. This helps us to collect all the demographic, financial responsibility, and other patient specific information we need to properly set up your account.
Notice of Privacy Practices
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) specifies the conditions under which protected health information may be used or disclosed by entities that maintain the records containing the protected health information. We have implemented safeguards to ensure adherence to the HIPAA privacy laws and have created the LIFECARE Privacy Notice to help patients better understand HIPAA and how it affects our practice. We ask that all patients read this document thoroughly and bring a signed copy of LIFECARE Receipt of Privacy Notice and Consent to Disclose Information document to the office at the time of your next visit.
Receipt of Privacy Notice and Consent to Disclose Information
This document confirms your receipt of our practice’s privacy notice. Your signature on this form also gives us permission to disclose any needed health care information to appropriate insurance companies and agents so that they can appropriately determine the benefits available for the delivered services.
General Authorization to Disclose Protected Health Information
This form is used to request your medical records from previous care providers and/or facilities . It is also used when you ask us to send your records to another facility.
Personal Representative Request Form
This form allows you to tell us which individuals you are giving permission to discuss your health information. The persons you identify on this form also have your authorization to make, reschedule, and cancel appointments on your behalf.
Personal Representative Request Form – Revocation
This form allows you to change your designation of a personal representative.
Advance Health Directives
In This Section
- Patient Forms
- Prescription Refill
- Referral Request
- Practice Policies
- Billing & Insurance
- Frequently Asked Questions
