Forms

The forms below are provided for your convenience and can be completed prior to arriving for your appointment.

Release Forms

Permission To Treat Authorization Form

TCC Permission to Treat Authorization Form

Health History Forms

Health History Under One Month

Health History Under One Month Spanish

Health History Over One Month

Health History Over One Month Spanish

Medical Receive / Release

Authorization-to-Release-Medical-Information-English-Spanish

Authorization-to-Receive-Medical-Information-English-Spanish

Behavioral Health Consent Forms

Behavioral Health Consent Form

Behavioral-Health-Consent-Form-Spanish

Portal Family Access

Portal Family Access For Patients with Special Healthcare Needs

Patient Portal Family Access Request

Genetic Research Notification and Opt-Out Statement

Notification and Opt-out Statement and Form

Patient Information and Consent - Influenza Vaccine

Patient Information and Consent – Influenza Vaccine

Virtual Visit Forms

Sport Forms

Generic Sports Form

SPORTS FORM INSTRUCTIONS: – Complete part one. If there are any “yes” answers please include a brief written explanation. – In order for the MD to sign part 2, part 1 must be completed for the MD to review. – Include the following information on the sports form:

Patient’s name and date of birth
Phone number and fax number (if applicable)
When the form is due
How you would like us to return the completed form. Options include: fax, mail, pick up at front desk, or email (through our patient portal) Please allow 2-3 days for us to complete the form.

IMPORTANT!!! If the patient’s most recent physical was over 2 years ago we CANNOT sign the form.

School Sports Pre-Participation Exam Form

New Patient Forms

Financial Policy Forms

Patient Financial Policy – English 08-2019

Patient Financial Policy – Spanish 08-2019

Patient Financial Policy Q&A – English 08-2019

Patient Financial Policy Q&A – Spanish 08-2019

Notice of Privacy Practices

Notice of Privacy Practices

Notice of Privacy Practices Spanish

Divorce, Seperation, and Custody

Divorce Custody Separation

Vaccine Policy

Patient Registration

Registration Form

Bill of Rights and Responsibilities

Patient Bill of Rights and Responsibilities

No Surprises Act