Patient Forms and Disclosures
- Health History Form (Required at First Visit)
- Parent Contact Information Form for Minors (Age 19 and Under) (Required at First Visit)
- Notice of Privacy Practices (NPP) HIPAA
- Receipt of NPP (Attachment to Form #3) (Required at First Visit)
- Dr. Mahalek's Pain Chart
- Authorization to Disclose Information
- Notice of Nondiscrimination and Accessibility (Aviso de No Discriminacion y Accessibilidad)
- Language Assistance Taglines
- Electronic Communication Agreement Electronic Communication Agreement (Revised 11.3.16) (Required at First Visit)
- Established Patient Reason For Visit Form (New Injury or Problem)
- Medicare Secondary Payer (MSP) Questionnaire
- Financial Policy
- Notice of the Right to Receive a Good Faith Estimate
- Notice of the Rights and Protections Against Surprise Medical Bills