Forms needed
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Membership Specific Forms |
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For all visits:
Read the Notice of Privacy Practices and sign the HIPAA form. Form also available on site at the clinic. For all fillable forms you must complete them in one sitting. Most will take you approximately 30-40 min. Chronic pain may take up to an hour to complete. 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
FEMALE
MALE
TELEMEDICINE
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Membership Fees are processed through a secure payment platform called hint.com which utilizes Stripe--To register for membership contact the clinic. After your initial appointment you can receive a link or fill out paper documents. Medicare B patients are ineligible for membership. If Medicare Advantage, please contact the clinic.
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Pediatrics | Well Child | Acute Care for Children
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INFORMATION ABOUT YOUR VISIT
We do not push any medical treatment at your visit. We support all decisions you make for your child.
We also provide exemptions upon request (additional fee added to wellness exam. No charge for members)
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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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