Forms
New Patient Forms Adult
New Patient Forms Child
Patient Consent Form for Privacy Rule
Patient Portal Agreement
Records Request (To or From Another Provider)
Consent for treatment of a minor child
Release of Information Form
Well Child Exam Questionnaire
Well Male Adolescent Questionnaire
Well Female Adolescent Questionnaire
Well Woman Questionnaire
Well Man Questionnaire
Policies
Treatment of a minor child
Any child who is under the age of 18 and is not yet a parent themselves, will need to have an adult accompany them to the office. If that adult is not the legal guardian of the child, you will need to have a “consent for treatment of a minor” form filled out prior to the office visit. The only exception to this policy is if a child under the age of 18 would like to be seen for counseling or treatment of pregnancy, pregnancy prevention or STDs.
Prescription refills
For the safety of the patient and the provider, it is not wise to prescribe medications for acute or chronic problems without an examination. For this reason, all patients need to have an appointment to obtain a refill of all medications. Your provider may choose to put refills on non-controlled medications. At the end of those refills, you will need to come back into the office for an appointment so we can assess and document the continued need of that medication and the current dosage. It is helpful for you to come to each visit prepared with a list or the bottles of medications that you need refills for.
We do not renew or call in new medications for any patient after hours. For our patients that are taking controlled medications, you will need to come in to the office every month for a refill. There are no exceptions to this policy.
Appointments
Our schedule is based on a same-day scheduling system. As a patient, you would call the day that you would like to be seen and we will help you with an appointment in our office. We do our very best to schedule patients accordingly so that our providers have the best opportunity to stay on time with their schedule. In an effort to stay on that schedule, we do ask all of our patients to arrive shortly before their scheduled appointment time. Patients who come late may forfeit their appointment time. If you are the last appointment of the morning or the afternoon, you will be informed of that when you make your appointment and they will remind you that you need to be on time or you will forfeit your appointment time even if you are only a few minutes late.
We do ask that all of our new patients come to their appointments at least 15 minutes early so they can fill out the necessary paperwork. The new patient paperwork is also available under “forms” on this website and if you would like to save time in our office, please print off the paperwork and fill it in prior to coming in.
Phone calls and questions to providers
We want to value the time and expense you put forth for your healthcare. In an effort to maximize your appointment time with our providers, we ask them to devote nearly all of their time during the workday to the patients that are in our office with appointments. Therefore, our providers are seeing patients during the day and are unable to consult with you by phone. We do have designated medical assistants to address your questions and/or problems. They will consult with your provider and make every attempt to get back with you within 24 hours.
After hours calls
One of our providers is on call for urgent medical situations when the office is closed until 10:00 PM. If you call our office after hours, you will be connected with the answering service. The “call back” phone number that you provide must be an “unblocked” phone line in order to receive a return call from the provider. Our providers do not have access to your chart while they are on call and so they will not be renewing prescriptions, making appointments or processing referrals. Please plan to make phone calls regarding those issues during the normal business hours.
If you ever have a medical emergency, please call 911 and direct yourself to the closest Emergency Room.
Medical records requests
At your first visit, a chart is created for the purpose of maintaining your medical records in accordance with state law. The chart is the property of the medical group. A copy of your medical chart can be provided to you for a fee once we receive a signed release form. It will take 7-10 business days to complete any medical records requests. The fee is $25.00 to burn your medical record to a CD and $35.00 to copy it onto paper. There is a link on our “forms” tab for our medical records request.
Forms/letters
There is a fee of $35.00 for our providers to fill out a form or write a letter on your behalf. You can forgo this fee if you would like to come in for an office visit specifically to address the form or letter. Please note that we do not fill out all forms, if you would like to inquire if it is a form we may fill out, you can call our medical assistants or bring it into the office at your visit. It may take the provider some additional time after your visit to fill out the form or generate a letter.
FMLA forms: If your employer is requiring that you have an FMLA form filled out, please bring that with you to your visit. If you find out after the visit that you need it filled out, you will need to get it to our office within 24 hours of your office visit or you will need to come back in for an appointment to have that form filled out.
Disability: We do not participate in the determination of long term disability. We will be happy to send medical records to whomever it is that you are working with on your disability. We will not fill out any form that asks us to describe functional capability or long-term disability prognosis.
