Patient Forms

Blood Pressure LogBlood Sugar Log

Use these forms to log blood pressure and 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, 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.

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.)