Forms

Statement of Extended Family Agreement – Filled out by the patient, when the patient who is no longer a minor, chooses to remain on their parent's account.

Authorization for Release of Medical Information – The authorization for release of information is needed for hard copy medical records.

NPP – HIPAA requires that patients receive the Notice of Privacy Practices (NPP) before their first service.  The NPP explains the patient privacy rights, the Clinic's responsibilities, how we may use and disclose their medical information and how to report a problem.  (en Español)

Revocation of Authorization – Filled out when a patient chooses to revoke a previously completed authorization.

Verbal Authorization – This verbal authorization is needed in order to share verbal medical information with family members or friends. (en Español)