Patient Forms

Extended Family Billing InfoStatement of Extended Family Agreement -  Filled out by the patient, when the patient--who is no longer a minor--chooses to remain on their parents' account.

Notice of Privacy Practices InfoNotice of Privacy Practices (NPP) - HIPAA requires 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
Large Print NPP

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

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

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

Authorization to Treat Minor Child InfoAuthorization to Treat Minor Child - Parents of minor children may request to have an alternate designee accompany the child for treatment, such as a family member, friend, or other caregiver.
en Español

Authorization & Assignment InfoAuthorization & Assignment - The form authorizes the clinic to disclose medical information in an effort to obtain proper payment from the patient’s insurance carrier and assigns those payment benefits to Springfield Clinic.
en Español

Agreement for Adult Child on Account InfoAgreement for Adult Child on Account - Filled out by the patient, when the patient—who is no longer a minor—chooses to remain on their parents’ account.

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