Patient History Sheet-both sides
This will assist your physician in making a diagnosis, assessing, and treating your present problem. This form also requests a list of your current medications, the dose, and how long you have taken each one.
Rheumatology Patient
History Form
If your appointment is scheduled with one of our Rheumatologists, Dr.
Kozlowski, please use this form.
Patient Registration Form
This form defines your consent to treat, release of information, financial responsibility and authorization to discuss your account. Medicare patients use this form to assign Medicare and Medi-Gap benefits.
Rehabilitation Therapy Patient Forms
If you have been referred to one of our Rehabilitation Therapy
centers, please complete this multi-page form and bring it to your first visit.
Worker Compensation Form
This form is for patients who have been injured on the job and have reported it to their employer and who wish to be seen as a Worker Compensation case. We must have permission from your employer to bill your visit as a Worker’s Compensation case and this form provides the necessary information for us.
Liability Claim Form
This form is for patients who have filed a liability claim against an insurance company for an injury that has occurred in an automobile accident or other accident. The form provides us with the necessary information to file a claim, once we have verified it, with the liability insurance company.
HIPAA NOTICE OF PRIVACY PRACTICES
This notice will tell you about the ways we may use and share medical information about you. It will also describe your rights and certain duties we have regarding the use and disclosure of medical information.
Payment Policy-both sides
This explains our policies and procedures involved with payment for sevices rendered at our facility.
