PATIENT FORMS


This page contains several forms that we use in our office. New patient forms, HIPPA forms, Release of information forms, and Breast MRI information forms.  You may find it convenient to download them and fill them out in advance of your visit.


New patient information forms can be downloaded by clicking on the "W" below  and printing them out so you can fill them out in advance of your visit.  If not they will be provided when you arrive for your examination.


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New Patient Information Form

Below please find the form for Release of Your Medical Information to my office.  If you need this form please click on the "X" below and  print out the form.  This can be sent off to help us obtain medical information that we will need to properly care for you.


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Authorization Form For Release Of Medical Information

Below please find information relating to the HIPPA laws.  These laws were set up to protect your privacy.  Feel free to either browse these or download them and print them out if you wish.  Please click on the "X" below to see them.


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HIPPA Laws

Below is our Consent for Release and Use Of Confidential Information and Receipt of Notice of  Privacy Practices.  This form will be given to you the first time you come to our office.  This allows us to bill your insurance company for their portion of your bill.  This form also acknowledges that you have been made aware of the new privacy practices and how it relates to your visit.  You can download this form in advance of your first visit to review and fill out, or wait and it will be provided for you when you arrive. 


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Consent For Release and Use of Confidential Information and Receipt of Privacy Practices

The link below has an information package about breast MRI that can be sent to your insurance company with the letter I have sent you(if appropriate) regarding breast MRI for high risk women.  The package contains an excerpt from the Blue Cross website, as well as an editorial from both JAMA and the NEJM showing the utility of breast MRI in high risk women.  I recommend making a copy of this information, as well as the letter, before you submit it to your insurance company, in case it gets lost.  In addition if you look on my "Patient Info" page there is an article from The American Cancer Society, with their recommendations for breast cancer screening, that can be printed and included with your packet to help your case.  Good Luck


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Breast MRI Information Packet
The link below contains information for the new "RED FLAG" rules pertaining to our policy to maintain our patients privacy by protecting their information to prevent identity theft.
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RED FLAG POLICY
MRI OFFICE AUTHORIZATION POLICY PAGE



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