Patient Forms

We have important documents that we ask you to review, fill out, and/or sign prior to your first office visit, and bring them with you to your appointment. Please fill out and sign the forms where requested, prior to coming to your first visit with us. Your check-in time will be greatly reduced if you can spend some time on these forms at home.

Registration Forms

• Medical/Personal History form: necessary for your physician
• Review of Systems for Physical Exam form: necessary for your physician
• Patient Registration form: provides us with your basic demographic and insurance information so that we can contact you as needed and bill your insurance appropriately. Please sign the bottom of this form and make sure to include proper subscriber information.
• Financial Policy form: to help you understand how and why billing is done. Please sign the bottom of the form as acknowledgement that you have read the information.
• Patient Consent form and Notice of Privacy Practices: allows us to treat you; for Medicare patients, allows us to release information as requested to the Social Security Administration; and provides acknowledgement of having received the Notice of Privacy Practices. Please initial the Privacy Practices statement (at bottom of form) and sign and date the bottom of this form
• Permission form: offers you the opportunity to designate individuals with whom you would like us to share information.
• Sender - Authorization for Release of Protected Health Information form: offers you the opportunity to allow for your medical records to be released from Beacon Internal Medicine to parties that you have designated on the form.
• Recipient - Authorization for Release of Protected Health Information form: offers you the opportunity to allow for your medical records to be released from parties that you have designated on the form to Beacon Internal Medicine.

Privacy Notices

This privacy notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

• Notice of Privacy Practices
• Aviso Sobre Las Practicas De Privacidad

These forms require Adobe Reader. If you do not have Adobe Reader, you may download it free here:

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