Patient Paperwork
The patient intake, consent to treat, and patient notice form below are to be completed by new patients.
Further down the page you will find the two release of information forms to be completed if you would like to send health records in or out of Integracare.
All forms can be completed/submitted online, or they can be printed and brought into the office.
Patient Intake Form
This paperwork asks about your symptoms that you will be seen for during your appointment.
Consent to Treat Form
This consent to treat must be signed prior to receiving care at the clinics.
Privacy Policy
This notice applies to the medical records maintained by this office and it specifically details how your medical information may be used and disclosed to third parties. This notice also details your individual rights regarding your medical records.
Authorization to Verbally Disclose Protected Health Information to Family and Friends
Integracare values your privacy, and we want to protect it as much as possible. By signing this form, you authorize Integracare to disclose information verbally (e.g. via phone, face-to-face) to the individual(s) you list below. This is separate from your emergency contact(s) and separate from an Authorization for Release of Health Information.
Release of Information
Sending Records OUT of Integracare
To be completed when sending information from Integracare to another medical facility.
Sending Records INTO Integracare
To be completed when sending information to Integracare from another medical facility.
To be completed when sending information to Integracare from another medical facility.
