Forms & Documents

Forms & Documents

We strive to provide the highest quality health care with the utmost in convenience. Forms that you may need for your healthcare in or out of our office are posted here. Please let us know if there are any forms that would be helpful that are not listed here.

New Patient Forms

1. New Patient Paperwork – must be filled out through the Patient Portal
2. Consent for the Release of Medical Information– (to allow Revolution Health to release your records to another medical facility)
3. Consent for the Release of information form (to allow other medical facilities to release your medical records to Revolution Health). 

HIPPA (Privacy) Forms

1. Medical Record Access Policy
2. Medical Record Amendment Form
3. HIPPA Authorization for use and disclosure of PHI
4. Business Associate Agreement
5. Confidential Communications Request Form
6. Confidentiality Policy
7. Confidentiality Policy
8. Patient Access to Medical Records Request Form
9. Patient Medical Record Access Policy
10. Medical Record Amendment Request Form
11. Medical Record Amendment Policy
12. Minimum Necessary Disclosure Policy
13. Accounting of Non-Authorized Disclosure Policy
14. Privacy Policy
15. Restriction of Use of PHI

 Fee Structure Information

1. Fee Structure Change Letter pdf