New Patient? Download, Read, then print and fill out the necessary New Patient Documents and bring them 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.
In preparation for your first visit review the following:
Instructions and Links to Individual Documents
1. Print and Fill out completely the Patient Demographics Worksheet and bring it with you.
2. Print and Fill out completely the New Patient Medical History and bring it with you.
Read the: HIPAA Notice of Privacy Practices
3. You will be asked to acknowledge receipt of this document during patient check-in by digital signature.
This acknowledgement confirms your receipt of the PVMED HIPAA Privacy Practices.
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
4. You will be asked to acknowledge receipt of this document during patient check-in by digital signature.
This consent gives PVMED permission to use your PHI for treatment, payment and health care operations.
Read the: PVMED Financial Policy
Read the: PVMED Financial Policy Acknowledgement
5. You will be asked to acknowledge receipt of this document during patient check-in by digital signature.
SecurFor existing Patients:
Protected Health Information (PHI) Release/Authorization Forms
Fill out PHI TO PVMED, and give 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.
DO NOT fax medical records to PVMED! DO NOT!
PVMED will take paper copies, if we must.
CDROM as PDF is an excellent way to send previous medical records.
The best way to send PVMED a copy of medical records is via electronic Direct Secure Messaging.
Ask your doctor to send via DM. DM is NOT email! Email is insecure, do not use email. The PVMED Direct Message address is found under Contact / Directions
Credit Card Agreement Authorizing Multiple Payments
If instructed by the PVMED office, print, fill out, sign, and return the top half of the the credit card agreement form. This form, when signed, authorizes PVMED to bill multiple transactions to your credit card. Return this form to the PVMED Office.
For security purposes, we do not permit this form to be filled out online or in a web browser.
A signed paper copy must be on file with the PVMED office.