Patient Forms

1. Notice of Privacy Practices (PDF) – Describes how health information about you (as a
   patient of this Care Center) may be used and disclosed, and how you can get access to
   your individually identifiable health information. Please review this notice carefully.
2. Authorization for Release of Medical Information (PDF) – Allows patients to authorize the
   disclosure of their health information to a designated individual, company, agency, or
   facility.
3. Authorization and Consent for Treatment (PDF) – All patients must provide their consent
   for treatment, communications (calls, emails, and text messaging), and agreement of
   financial responsibility. Autorización y Consentimiento Para el Tratamiento
4. Preferred Contacts (PDF) – Patients are encouraged to complete and return the Preferred
   Contacts Form but it is not required. Contactos Preferidos
5. Financial Policy (PDF) – This form advises patients of their complete financial responsibility
   for all medical services received without regard to insurance eligibility or coverage
   determinations.
6. Language Services