Please document your personal information, emergency contact, pharmacy of preference and medical insurance information. We will scan your insurance cards and photo ID so please bring them in with you to your appointment.
Social and Medical History
Please provide us with your social, medical, family history and list of current medications.
The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule gives individuals a right to be informed of the privacy practices of their health plans and of most of their health care providers, as well as to be informed of their individual rights with respect to their protected health information (PHI). By signing this section of the form, you consent to our use and disclosure of PHI, payment and health care operations within medical offices and organizations involved with your care.
Third Party PHI authorization
This is an optional form.
Please let us know the name of anyone (spouse, children, relatives, or friends) you would like to give permission to access and request your health record. If there is no one you would like to authorize please write “none” or put a line across the page and sign.
This document outlines our standard billing practices. As a courtesy to our patients we will bill their health insurance carrier(s) for medically necessary visits and procedures. In order to do this properly and in a timely manner, we will need accurate insurance information. We also ask that you pay close attention to our policies regarding 1) coinsurance, co-pays, account balances and insufficient funds, 2) biopsies, and 3) the option to leave a credit card on file.
Maps and contact information for our Johns Creek office.
We look forward to seeing you soon.