Forms needed
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Membership Specific Forms |
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For all visits:
Read the Notice of Privacy Practices (above) and sign the below HIPAA form. Everyone needs the following:Release of Protected Health Information: optional--allows for transfer of health information from your previous provider or other entities.
HEALTH HISTORY
TELEMEDICINE
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Membership Fees are processed through a secure platform called hint.com --To register for membership contact the clinic. Medicare B patients are ineligable for membership. If Medicare Advantage, please contact the clinic.
All information will be confirmed by clinic staff prior to first payment. If you would prefer manual entry use the buttons under Forms Needed. |
Pediatrics | Well Child | Acute Care for Children
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INFORMATION ABOUT YOUR VISIT
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HEALTH HISTORY
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Other Forms
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Sports Physicals and other Physicals
This form is a general school physical form and is widely accepted at most schools. This form can also be used for employment. Please have other specific forms available at time of visit if needed.
For walk-in, please print, pre-complete and bring the following with you or arrive 10 min early to complete.
CHRONIC PAIN
For Medicare B and Pain Membership Only.
-Members: in addition to normal membership paperwork |
DOT/CDL FORMS
You will be provided an instant copy of certification after the completion of the exam IF you qualify. If other supporting documentation is needed you will get a 50% refund which can be repaid once the documentation is obtained and you complete the exam requirements.
Examples of needed documentation:
**IF you need assistance in obtaining these please use the contact us form to schedule for these in office tests (extra fee for non-members). For walk-in, please print, pre-complete and bring the following with you to speed up the check in process. or arrive 20 minutes early. You will have to provide a urine sample for chemical dip only. Drug tox is not apart of this exam.
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