Forms

Patient Information Sheet (Click Here)

New patient form

This form is required of all patients 1) provides contact information necessary to reach the patient by phone or mail 2) authorizes the practice to release health information required by health insurance companies listed and 3) authorizes us to bill insurance for visits and/or collect patient responsibility for billed charges at the time of service.

Financial Policy (Click Here)

New patient form

This form explains the billing process, practice obligations and patient obligations related to payment for medical services. Fees for returned checks, missed appointments and past due accounts turned to collection/tracking are identified. This form stresses the importance of 1) updating insurance information; 2) updating contact information; and 3) taking a proactive role in the payment of claims.

Health History

New patient form

This form gathers past medical history on new patients or patients who have not been in the office recently. This past medical history includes family illness, past and current medication, surgeries and selected procedures as well as social activities with risk factors.

Lab Results Consent (Click Here)

New patient form

This form allows a patient to allow Sparks Family Medicine to call lab results to a phone number provided by the patient. Patients who do not choose to allow lab results to be called to them will be asked to schedule an appointment to be informed of lab results, (even if these results are normal).

Patient Acknowledgement of Privacy Practices (Click Here)

New patient form

Notice of Privacy Practices (Click Here)

The Patient Acknowledgement of Privacy Practices documents the patient's receipt of the Notice of Privacy Practices as required by HIPAA. Only the Patient Acknowledgement form needs to be included in new patient paperwork.

Arbitration Agreement  (Click Here)

New patient form

Sparks Family Medicine requires patients to sign the Arbitration Agreement form, which states that patients agree to arbitrate disputes rather than pursue a jury trial.

Medical Records Release #1(Click Here)

New patient form (Optional)

Completion of this form is necessary to request a patient's medical records from another health care provider. A fax number for the health care provider's office is required. Patients can limit the type of health care information requested or select "All Records." Medical Records Release #2 should be used to request that Sparks Family Medicine transfer your records to another health care provider.

Medical Records Release #2 (Click Here)

This form will allow you to request that your records be transferred to another health care provider. Patients can limit the type of health care information requested or select "All Records."