Patient Forms
Blood Pressure Log
Use these forms to log blood pressure information.
Blood Sugar Log
Use these forms to log blood sugar information.
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, appointments, or 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.
HIPAA Notice of Privacy Practices / La Nota de HIPAA de Prácticas de Intimidad
This notice describes how information about you may be used and disclosed and how you can get access to this information. (Available in English and Spanish.)
