Forms

For your convenience and to speed the process, you may complete some of the paperwork in advance by printing it out ahead of time and bringing it with you already filled out and signed. If you are interested in this option, see the listing of items below available for advance completion:

New Patient Forms -

O Registration Form

O Financial Policy

O HIPAA Privacy Statement - 2 Parts

O Parental Consent for Treatment Form

(You must have this form to receive treatment if under the age if 18.)

Medical Record Copying Form* -

O Authorization for Release of Information (Click here to download this form in PDF format)

* Record Copying Fees - Piedmont Internal Medicine routinely copies limited records free of charge for patients and other providers involved in the care of our patients. However, when records are requested by insurance companies, attorneys, employers, courts, or patients leaving the practice, or when sections of records or entire records are being requested, fees are assessed to the requesting party to cover the costs associated with such copying – these fees are set by the Commonwealth of Virginia.

Medicare Wellness Form* -

O Medicare Wellness Worksheet (Click here to download this form in PDF format)

*If you have Medicare and are scheduled for a routine physical examination, that your doctor recommends periodically as an important part of your overall wellness care, unfortunately, Medicare does not cover this wellness care. The exceptions to this policy are for pelvic exams and pap smears for women, and prostate exams for men. No other components of your wellness exam will likely be covered by Medicare, and therefore will be your payment responsibility (unless covered in part by a secondary insurance plan.) Please download this form and bring it with you on your next physical exam.