Notice of Privacy Practices

(Updated November 25, 2020)

This notice describes how your medical information may be used and disclosed

and your access and rights to this information.

New Patient Paperwork

*Please fill out and send back via email, fax, or mail (if we will receive it before your appointment date).

*You may also drop off or bring your paperwork with you to your appointment.

Patient Authorization for Release of Medical Records

*If you need us to receive any medical records from another physician you have seen, please fill out this form and send it to us via email, fax, mail, or you can come by the clinic and drop it off.

*Once we receive the form, we will fax it to the designated physician.

Minor Consent Form

*If your child is a patient and they are coming in with someone other than a parent/guardian or they are coming in alone and are still a minor (Under 19 in AL), please fill out this form.

*You can email, fax, or mail (if we will receive it before the appointment date) this form to us or you can have your child bring it with them to the appointment.

Patient Referral Form

*Provider-only form

*If you are a provider or office wanting to refer your patient, please print and fax this form to our office along with office notes, pathology results, and any other kind of information that we may need.