Patient Forms and Disclosures

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

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