PVMED Forms

1.  Print and Fill out completely the Patient Demographics Worksheet
and bring it with you. 

Do you have a PVMED  PORTAL account?  This information can be filled out online.

Contact the PVMED office to get your portal account set up before your first visit.

2.  Print and Fill out completely the New Patient Medical History and bring it with you.

Do you have a PVMED  PORTAL account?  This information can be filled out online.

Contact the PVMED office to get your portal account set up before your first visit.

Read the: PVMED HIPAA Notice of Privacy Practices

3.  You will be asked to acknowledge receipt of this document during patient check-in by digital signature.

• • Acknowledgement at the PVMED office will confirm receipt of the PVMED HIPAA Privacy Practices.

  • Acknowledgement at the PVMED office will confirm consent for Use and Disclosure of PHI by PVMED  per our HIPAA Notice of Privacy Practice.

  • This consent gives PVMED permission to speak to Third Parties per your specific instruction

• • Optionally, fill out completely the HIPAA Consent for Disclosure of PHI to Third Parties

Read the: PVMED Financial Policy

4.  You will be asked to acknowledge receipt of this document during patient check-in by digital signature.

5.  If you are a Medicare patient, you must sign this document during patient check-in by digital signature.  You may read the blank form now.

Medicare Signature Authorization Form

For New Patients:

Protected Health Information (PHI)
RELEASE Authorization Form

*Authorization to release PHI TO PVMED

Transferring your medical records into PVMED?
Fill out Authorization to release PHI to PVMED, and give to your current provider.  This is a 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 large multi-page medical records to PVMED!  DO NOT!

• PVMED will take paper copies, if we must.  We do not want paper copies.

• CDROM as CCD/PDF is preferred and is an excellent way to send medical records.

• The best way to send  PVMED a copy of medical records is CCD through secure Direct  Messaging.  Ask your health provider 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 

For Existing Patients:

Protected Health Information (PHI)
REQUEST Authorization Form

*Authorization to request PHI FROM PVMED

Transferring your medical records out of PVMED? 
Fill out form Authorization to Request PHI from PVMED, and give to the PVMED office to request a copy of your medical records.  PVMED may charge fees for the release of medical records. See  the form below, Medical Record Request Fees and Charges. 

Read our Medical Record Transfer Request Policy, summarized below:

• The best way to send medical records is a C-CDA CCD through Direct Messaging.  Ask your provider to send PVMED a DM with their own PHI release form!  We will respond with a copy of your records. DM is NOT email!  Email is insecure, do not use email.  The PVMED Direct Message address is found under Contact / Directions 

• PVMED charges fees to FAX large medical records to another health provider or the patient.

• PVMED charges fees to make paper medical record copies for patients or providers et. al.

• Patients requesting a CDROM copy of their records will be provided those records free of charge.  The PVMED patient must pick up the CDROM at the PVMED office, otherwise a shipping charge will apply.  Give the CDROM to your new health provider.

• Shipping a CDROM to a health provider directly, is available based on policy