Patient Forms

Patient Registration Forms

• Medical History Form – (New Patients)
• Office Visit History Form – (Returning Patients)
• Registration Record
• Consent for Treatment
• Arbitration Agreement (2018)
• HIPPA Notice of Privacy Practices
• HIPPA
• Payment Agreement

Patient Consent Forms

• ERCP Consent and Risk Assessment

Release of Information Forms

• Authorization for Release of Protected Health Information (for records from another Dr. office) – Dr. Gonzales and Ruth Earley
• Authorization for Release of Protected Health Information (for records to be sent to another Dr office) – Dr. Gonzales and Ruth Earley