Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.
David S. Deuser M.D. & Associates Forms
Please print and fill out all paperwork prior to coming to your appointment. Please note there are 3 packets below and depending upon the age of the patient you will need to complete either 2 or 3 packets. Please call the office if you have questions.
PACKET FOR AGES 16-ADULT
PACKET FOR AGES 18 AND YOUNGER
ALL PATIENTS MUST COMPLETE
Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente
Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento
Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.
Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)
Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)