PVMED Forms

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.

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.


1.3 New Patient Demographics Worksheet.pdf

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.


2 New Patient Medical History.pdf

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

3 PVMED HIPAA Notice of Privacy Practices.pdf


4 HIPAA Consent Form for Disclosure of PHI to Third Parties.pdf

Read the: PVMED Financial Policy

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

5.2 PVMED Financial Policy.pdf

5. If you are a Medicare patient, you must sign this document during patient check-in by digital signature. You may optionally print it now.

Medicare Signature Authorization Form

6 Medicare Signature Authorization Form.pdf
6 Auth Release of PHI To PVMED PCC-Arto v6-FORM.pdf

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

7 Auth Release of PHI From PVMED PCC-Arfrom v7-FORM.pdf

Medical Record Request Fees and Charges 2022

2022 PVMED Medical Record Request Fees v3.pdf
PVMED Credit Card Authorization Form.pdf

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.