Electronic Communications/Telehealth Informed Consent

Electronic Communications Telehealth Informed Consent

New Patient Forms

If you have not completed your new patient paperwork in advance, please arrive 45 minutes early for your appointment to allow time to do so. You can submit completed forms in advance below. Forms must include the patient’s or legal guardian’s actual signature; computer generated text signatures cannot be accepted. 

If you are an adult, please fully complete, sign and date these forms prior to your first appointment. You do not need to return the HIPAA notice form; it is for your records. Adult New Patient Forms

If you are assisting an adult who cannot complete forms independently, please help them to fully complete, sign and date these forms prior to your first appointment. You do not need to return the HIPAA notice form; it is for your records. Assisted Adult New Patient Forms

If you are the parent or legal guardian of a child, please fully complete, sign and date these forms prior to your first appointment. You do not need to return the HIPAA notice form; it is for your records. Pediatric New Patient Forms

Records Request Form

To request that your records be sent to you or another party, fully complete this form and mail or fax it to the office. Once the completed form has been received and it is determined that the requested information exists and can be released, your records will be released within fifteen days. Forms must include the patient’s or legal guardian’s actual signature; computer generated text signatures cannot be accepted. If you submit a form on a day the office is closed, the date of receipt of that form will NOT be the day it was sent by you, it will be the day it was actually opened and viewed by Dr. Emick or a member of her staff. Authorization to Release Exchange Information Form

Submit Forms

Click or drag a file to this area to upload.
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