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Filling Out a Medical Form

 

Forms 

New Patient Forms

Please print the following new patient appointment forms and bring with you to your first appointment. We ask you arrive 15 minutes early and bring your most recent Insurance ID Card.

Patient Information Form

 

Patient Acknowledgement and Consent Form

 

Authorization to Transfer Records

 

Medical/Social History Form

 

Appointment Cancellation/No Show Policy

 

Privacy Notices

 

Financial Policy

 

 

We want ensure time is given to every patient of the practice and that each patients needs are addressed. Therefore we ask if you need too reschedule your appointment, at least a 24 hour notice is given. New patients whom No-Show to the first appointment will not be rescheduled. 

 

 

 

 

 

Sports Form

If your child needs to be seen for a sports physical, please print out the form below. Please complete all pages prior to the appointment so that the provider can review the pertinent health information before doing the physical exam.

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Medical Records

Most states, including Ohio, do not have specific laws mandating the minimum record retention period for patient medical records. However, HIPAA and the Ohio Medicaid rules mandates the retention of records for a period of at least six

(6) years after payment of the claim to the provider.

For consistency purposes, it is also recommended that records relating to Medicare beneficiaries be kept for at least six (6) years as well although Medicare Conditions of

Participation only requires a five (5) year retention period.

If you would like to make a medical records request please contact our medical records clerk at 937-848-4121.

If your a patient needing medical records transferred please fill out the blow form and submit to our medical records clerk.

 

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