New Patient? Download, print, and fill out the New Patient Documentation Package and bring it with you on your first visit.
Existing patient? Need a copy of your medical record, or want to otherwise release your protected health information? See below.
Above, download, print, fill out, sign, and bring the entire documentation package with you on your first visit.
Instructions and Links to Individual Documents
1. Fill out completely the Patient Demographics Worksheet
2. Fill out completely the New Patient Medical History
Read the: HIPAA Notice of Privacy Practices
3. Optionally, fill out completely the HIPAA Consent for Disclosure of PHI to Third Parties
- This consent gives PVMED permission to speak to Third Parties per your specific instruction
- This consent gives PVMED to use your PHI for treatment, payment and health care operations.
Read the: PVMED Financial Policy
6. Sign the PVMED Financial Policy Acknowledgement
If you do not bring signed acknowledgements 4,5,and 6 on paper, you may digitally sign these three documents in our office.
New PatientProtected Health Information (PHI) Release/Authorization Forms
Take a copy of this filled out form to your current physician, to request that a copy of your medical records be sent to PVMED. Be aware that your provider may use their own forms, and they may charge you fees to make copies of your medical records. PVMED will take paper copies, but we prefer fax, or any available electronic format.
For existing Patients:
Protected Health Information (PHI) Release/Authorization Forms
A copy of the same form, but this one is used to request the release of your information from PVMED, and sent to another requesting party. PVMED is discouraged by the high fees charged by other practices for copies of patient records, and makes electronic copies of a patient's records available for free.
If a patient (or other party) requests a paper copy of their records, our fees follow this schedule allowed by Pennsylvania Law: