Patient Forms

To save time at your appointment we have provided the following forms for download.  You will need the free Adobe Acrobat Reader to open and print the form.  Please print out the form as instructed by your provider, fill it out and bring it with you.

All Providers

Notice of Nondiscrimination and Accessibility

Notice of Privacy Practices – Please review prior to your first appointment.

Please print, complete the following forms, and bring with you to your first appointment.

• • Receipt of Privacy Practices Notice
  • Financial Policy
  • Authorization For Medical Records Release
    

    Dr. Taube

    Please print, complete the following forms, and bring with you to your first appointment.

    • • Verification of Benefits
      • Financial Policy
      • No Show Policy
      • Authorization for Disclosure of Protected Health Information
      • Patient Registration Form
      • Prescription Renewals Policy

    Medical Record Request Form – Release Records from Dr. Taube’s Office – Please print, complete the form, and return to Dr. Taube’s office to have records from Dr. Taube’s office sent to another physician or to request a personal copy of patient chart.

    Medical Record Request Form – Request Records to be sent to Dr. Taube’s Office – Please print, complete the form, and return to Dr. Taube’s office to have records sent from another doctor to Dr. Taube’s office.

    Pediatric Associates

    Authorization for Treatment of a Minor – Please print, complete the form, and bring with you to first appointment.

    Dr. Brantley and Dr. Ham

    Please print, complete the following forms, and bring with you to your first appointment.

    • • Patient Information Form
      • Patient Medical History

    Medical Record Request Form – Request Records to be sent to Dr. Brantley/Ham’s Office – Please print, complete the form, and return to Dr. Brantley/Ham’s office to have records sent from another doctor to Dr. Brantley/Ham’s office.

    Medical Record Request Form – Request Records to be sent from Dr. Brantley/Ham’s Office – Please print, complete the form, and return to Dr. Brantley/Ham’s office to have records sent from Dr. Brantley/Ham’s Office to another doctor or to request a personal copy of patient chart.