For your convenience and to speed the process, you may complete some of our 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. You must have Adobe Acrobat Reader to download these forms. Click here to download Adobe Acrobat Reader to your system.
New Patient Forms - All of the forms below are required for all new patients at their first visit.*
O Registration Form O Financial Policy O HIPAA Privacy StatementO Parental Consent for Treatment of Minors Form (*You must have this form to receive treatment if you are under the age of 18.)Medicare Wellness Form - If you are scheduled for a Medicare Wellness Physical, this form is required and must be completed prior to your appointment time.
O Medicare Physical Form
Medical Record Release Form* - Whether you need to obtain your records from us or send us records from elsewhere, you must authorize using the respective form below.
O Authorization for Release of Information
* 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 State of Virginia.
Forms
Telephone:
(540) 347-4200
(540) 341-7102 (fax)
