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OFFICE FORMS
If you are a New Patient, you may Download and Print the Forms below at home, and read and enter the information.
If you forgot your Forms / have not filled them out prior to the first appointment, they can be found on the Green Clip Board in the Waiting Area.
I cannot see you without these completed Forms!
Every New Patient is required to complete:
(1) Patient Registration Form (registration.pdf) ,
(2) Patient Confidential History Form (Patient_history.pdf), and
(3) Patient Acknowledgement Form (patientacknowledgementeng-span.pdf).
If you have had a Brain Insult (Traumatic, Metabolic or Emotional) or Chronic Fatigue-type Symptoms, please download the Brain Injury Questionnaire below (mtbi_rivermead). Make sure that you read the Scoring details at the top of the form. This can save a lot of time describing your symptoms, as so many symptoms are listed on the Questionnaire.
If you are a Medicare Patient, there are several circumstances that mandate that you read and complete the Medicare Private Contract Form (medicare_private_contract.pdf) below - these include:
(A) every New Patient who has Medicare;
(B) every Established Patient who has Changed their Insurance to Medicare, and
(C) every returning Medicare Patient, Annually, per Federal Law.
If you would like to read a copy of the Federal "Notice of Privacy Practices" (hipaa-article.pdf), this is available below. Although there is nothing to complete on this last Form, and it does not have to be printed, I have included it here as you are required to acknowledge, by Federal Law, that you have the opportunity to view it.
Thank you for visiting our website, I look forward to seeing you in the office!
Dr Gaydos
© James Edward Gaydos DO, 2016. All Rights Reserved.
If you are a New Patient, you may Download and Print the Forms below at home, and read and enter the information.
If you forgot your Forms / have not filled them out prior to the first appointment, they can be found on the Green Clip Board in the Waiting Area.
I cannot see you without these completed Forms!
Every New Patient is required to complete:
(1) Patient Registration Form (registration.pdf) ,
(2) Patient Confidential History Form (Patient_history.pdf), and
(3) Patient Acknowledgement Form (patientacknowledgementeng-span.pdf).
If you have had a Brain Insult (Traumatic, Metabolic or Emotional) or Chronic Fatigue-type Symptoms, please download the Brain Injury Questionnaire below (mtbi_rivermead). Make sure that you read the Scoring details at the top of the form. This can save a lot of time describing your symptoms, as so many symptoms are listed on the Questionnaire.
If you are a Medicare Patient, there are several circumstances that mandate that you read and complete the Medicare Private Contract Form (medicare_private_contract.pdf) below - these include:
(A) every New Patient who has Medicare;
(B) every Established Patient who has Changed their Insurance to Medicare, and
(C) every returning Medicare Patient, Annually, per Federal Law.
If you would like to read a copy of the Federal "Notice of Privacy Practices" (hipaa-article.pdf), this is available below. Although there is nothing to complete on this last Form, and it does not have to be printed, I have included it here as you are required to acknowledge, by Federal Law, that you have the opportunity to view it.
Thank you for visiting our website, I look forward to seeing you in the office!
Dr Gaydos
© James Edward Gaydos DO, 2016. All Rights Reserved.
| registration.pdf |
| patient_history.pdf |
| patientacknowledgementeng-span.pdf |
| mtbi_rivermead.pdf |
| medicare_private_contract.pdf |
| hipaa_article.pdf |
