Patient Forms
Please click the links to download the 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. - 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. - 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 financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
- Language Services