Prior to your first visit at any of our Frederick, Hagerstown or Urbana locations you will need to complete the forms below. Please download the appropriate form as directed by your physician and/or staff by clicking on the name of the form. If you cannot access the form, please click on the Adobe Reader icon. This will allow you to download this software, providing access to the forms. Please bring the completed form(s) with you to your scheduled visit. This will help expedite the registration process. Thank you.
* For your convenience, these are ‘fillable’ forms into which you may type the required information, or you may print out the blank forms and fill them in by hand. Once completed, please sign them and bring them to our office at the time of your appointment. Please note, you cannot save data typed into this form, therefore, it must be printed out immediately after it is filled in. If you navigate away from this form, the information will not be saved and the form will be blank. Once completed, please print it out immediately.
- Patient History Form
- Patient Registration Form*
- Payment Policy Form*
- PIP Authorization Form*
- Workers’ Compensation Form*
- Notice of Privacy Practices
- Acknowledgement of Receipt of Privacy Practices Form*
If you cannot access the forms you can click on the icon to download the software.