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 Health Information Receive or Disclose Information
  7. Foot and Ankle MRI Screening Form
  8. Hand, Wrist, and Finger MRI Screening Form
  9. Knee MRI Screening Form
  10. Pelvis and Hip MRI Screening Form
  11. Shoulder and Elbow MRI Screening Form
  12. Spine MRI Screening Form
  13. Notice of Nondiscrimination and Accessibility (Aviso de No Discriminacion y Accessibilidad)
  14. Language Assistance Taglines
  15. Electronic Communication Agreement Electronic Communication Agreement (Revised 11.3.16) (Required at First Visit)
  16. Established Patient Reason For Visit Form (New Injury or Problem)
  17. Medicare Secondary Payer Questionnaire
  18. Financial Policy
  19. Notice of the Right to Receive a Good Faith Estimate
  20. Notice of the Rights and Protections Against Surprise Medical Bills



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