New Patient Information

new-patient-information
Linked below are new patient forms needed for your upcoming appointment. Please follow the steps below to complete your new patient information. Then print and complete the following two forms (the Acknowledgment of Receipt of Notice of Privacy Practices and the HIPPA Notice of Privacy Practices) and return them by mail or fax, as soon as possible, along with a copy of your insurance card (front and back). If your insurance requires a referral and you have received it, please enclose a copy of the referral. We must have a copy of your insurance card (front and back) in order to verify benefits and be prepared for your visit. The “Notice of Privacy Practices” is for your records and we do not need it returned.

Please note that patients who do not cancel their appointment 24 hours before and/or miss their appointment will be charged $35.00 for a missed routine visit and $100.00 for a missed surgical procedure.

Thank you, in advance, for your cooperation in assisting us with being prepared for your appointment. We hope your visit is a pleasant one.

Step 1: Download and read the instructions for new patient demographics.

Instructions for Patient Demographics

Step 2: Click on Patient Login to complete the registration process.

Step 3: Download, print and complete the following privacy notices. Please bring these documents to your appointment.

Acknowledgement of Review of Privacy Practices
HIPAA Notice of Privacy Practices

Here’s a list of other forms and resources on our site:

If you have any questions about our forms or need help filling them out, please contact us.

Forms

Medical Release Form

Linked below are the Medical Records Release Form needed for your upcoming appointment. Please print and complete the following form.

Thank you, in advance, for your cooperation in assisting us with being prepared for your appointment. We hope your visit is a pleasant one.

Authorization Form FROM BDA Authorization Form FROM BDA Authorization Form TO BDA Authorization Form TO BDA

Consent to See a Minor Form

Linked below Consent to See a Minor Form needed for your upcoming appointment. Please print and complete the following form.

Thank you, in advance, for your cooperation in assisting us with being prepared for your appointment. We hope your visit is a pleasant one.

Consent to See a Minor Form Consent to See a Minor Form