Patient Forms

Forms
Form Name Description
Advanced Directive Form (PDF) -
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.
Fax Coversheet (PDF) -
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.
Flu Vaccine Form (PDF) -
Patient Registration Form (PDF) Information required from our new patients.
Patient Medical History (PDF) Includes medications, allergies, past/current medical conditions, hospitalization and surgery history, family and immunization history.
Notice of Privacy Practices Acknowledgement Form (PDF) Describes how health information about you may be used and disclosed, and how you can get access to your individually identifiable health information.
Patient Rights Information Packet (PDF) This packet explains your rights, our responsibilities, and how we typically use and share your information.
Semaglutide Schedule and Cost -
Semaglutide Weight Loss Tips -
Virtual Visit Technology Policy

Virtual Visit Technology Policy

Our Commitment to Your Privacy

Our Care Center is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). In conducting our business, we will create records regarding you and the treatment and services we provide.

The technology we use for virtual visits does not record your protected health information (PHI) in any way. Documentation for your virtual visit is completed in the same manner as an in-office visit, using your provider's electronic medical record (EMR) system. The same privacy practices apply to both in-office and virtual visits. For additional details, please review our Notice of Privacy Practices.

Virtual Visit Technical Process

The Health Insurance Portability and Accountability Act (HIPAA) provides standards to protect the confidentiality, integrity, and availability of protected health information (PHI), including electronic PHI (ePHI). HIPAA guidance helps ensure ePHI security while enabling providers to access necessary information.

Our virtual visit platform supports video communication in a way that aligns with HIPAA obligations.

  • The technology does not store or access PHI.
  • Encryption protects video streams during transmission, preventing unauthorized access during a session.
  • Recording of videoconferencing sessions is disabled for both patients and providers.

Access Authentication and Security Controls

All registered system users have a unique username and must authenticate with a password through their EMR to access the virtual meeting room. Unique keys are generated for each scheduled visit. Providers, designated moderators, or system administrators can terminate any meeting.

Audit Controls

  • Failed authentication attempts are recorded and monitored for unauthorized access signs.
  • Configuration changes to the virtual visit system are monitored and recorded to prevent unauthorized modifications.

Transmission Security

Our platform employs various security measures at both the application and network levels:

  • Application Level: The platform meets enterprise security standards using TLS, SRTP, H.235 (for legacy interoperability), and AES 128-bit encryption for signaling and media.
  • Network Level: Hosting facilities are SOC 2 compliant with 24/7 security. Firewalls are routinely assessed, configured, and updated to remain effective against intrusions. Advanced filtering and routing help protect against Distributed Denial of Service (DDoS) attacks.

Staff & office info

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