The forms listed below are available for our patients’ convenience. You many download, print and complete the forms prior to coming in for an appointment. We hope bringing these completed forms with you will save time and make your arrival and visit easier.
Contact Information Update & Patient Portal Activation Form – it is important for us to have up-to-date contact information to be able to reach you with test results, appointment information or other vital information. We all know how email addresses, cell phone numbers and addresses change over time. Completing this when you are coming in for an appointment or other times when you know you’ve had a status change is important. This form also enables Patient Portal Activation if desired.
HIPAA (Notice of Privacy Practices) – This document is informational only, nothing to fill-out or sign.
Patient Registration Form – Please complete this registration form in its entirety and sign the bottom of the Assignment of Benefits section (authorizing us to bill your insurance) as well as the Acknowledgement of Receipt of Privacy Practices section. Our Notice of Privacy Practices is posted in all of our offices and may be accessed by clicking the link above.
Verbal Disclosure of Information Authorization Form – This form authorizes the physicians or staff at WHCMA to discuss aspects of your protected health information with designated family members or others whom you specify. We ask you to indicate your preferences regarding receipt of messages from our office for communications such as telephone appointment confirmations or test results.
WHCMA Authorization for the Disclosure of PHI (Medical Record Release) – This form may be used either to request records from others be released to WHCMA or for WHCMA to release records to other parties.
Urogynecology NEW Patient Questionnaire