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Doctor Checking a Form

Patient Forms

Resources and forms for new patients using select services with Integrated Medical Services are provided below. 

General Forms

English Forms
Patient Registration Form
Medical Records Request
Spanish Forms
Autorización para divulgar información médica

Specialty Forms

Primary Care
Podiatry
General Surgery
Gastroenterology
Neurology
Pain Management
Cardiology
Ear Nose and Throat
Endocrinology

IMS and PRIVIA Patient Forms

General Forms

Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.

Notice of Privacy Practices

Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.

Authorization for Release of Medical Information

All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Authorization and Consent for Treatment

Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Preferred Contacts

This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.

Financial Policy

Language Services
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