Patient Forms

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Thank you for your interest in becoming a patient. For your convenience, please print and fill out the forms below so we may serve you more efficiently and minimize your wait time.

Fill out and bring them with you to your first appointment, along with your insurance card and photo ID.

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New Patient Forms

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             Download New Patient Forms

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Patient Portal Agreement

 

             Download Patient Ally Agreement

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Medical Record Release Form

     

             Download Medical Release Form

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Notice of Privacy Practice

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             Download Notice of Privacy Practice

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Policies

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Medication Refill Request

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Please call your pharmacy for any prescription refill requests. In an effort to provide our patients with the safest, most efficient service possible, we are no longer accepting prescription refill requests by phone. Please call your pharmacy to request a medication refill before you are out of your medication. Your pharmacy will then send us a request with your medication name and dosage. Your provider will then review the request, and a response will be faxed back to the pharmacy. Your pharmacy will contact you when the medication is ready. Therefore, it may take up to 72 hours for your prescription to be ready. It is wise to notify the pharmacy one week before you are expecting to be out of your medication.

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Lab Results, Imaging test, and referrals

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For Lab And Imaging Results:

Please allow seven days (one week) for us to receive and review the results (unless it was an urgent request). We will notify you of your results and sometimes it can take longer then anticipated due to a delay in reporting of the lab results or the work flow. You may contact the office and bring it to our attention, if you have not heard from us. We apologize for any inconvenience. 

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Referrals And Authorizations: 

The referral request are submitted by the office. Please expect your authorizations to arrive in the mail at your home address that was given to the insurance plan. The authorization should arrive within 2 weeks. If there is any concern about your authorization approval or physician chosen by the IPA, please call your assigned IPA medical group directly. The phone numbers are on your insurance card. 

 

Please note that Behavioral Health services are self referral for patients with an assigned medical group and therefore, no referral is needed. You may call the number on your insurance card or call your health plan for further information.