Patient Forms
| Patient Profile & History Form |
Our standard patient profile we have all of our patients fill out at the time of their exam with us. VSP members are the only exception to this, as VSP has its own Patient History form they use.
| HIPAA Acknowledgement Form |
This form is our "acknowledgement of privacy policies" form. It is voluntary, however we ask that all patients review it, and either sign or decline it. This form may only be signed by patients 18 years of age or older who are not covered as a minor dependant under an insurance policy. For all patients classified as minors (under 18 years old or a dependant on a parent/guardian's insurance policy), this form be signed/declined by the child's parent or legal guardian before services may be provided.
| Payment Responsibility Form |
This form is our office's "payment responsibility" form. This form must be signed prior to services being rendered. This form must be signed by a parent/legal guardian for all minors and insured dependants (any child listed as a dependant on the insurance policy, or in lieu of insurance coverage, any minor under 18 years of age). This form is required for all patients.