Patient Forms

Authorization for Use & Disclosure of Protected Health Information (PHI) Release of Information

Use this form to authorize release of your medical information.


Appointment of Authorized Representative 

Use this form to give your provider and provider’s office authorization to discuss your health care, discuss appointments, or discuss directives with others; to allow someone other than yourself to pick up medications and prescriptions for you; or to discuss your medical billing account with someone other than yourself.


Sliding Fee Discount Program

This program offers eligible patients four levels of discounts for services provided at our centers. Please complete the application and return it to us within 30 days for processing.