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Patient Forms

Notice of Privacy Practices 

Laureate Medical Group's Notice or Privacy Practices describes how your medical information may be used or disclosed. Please review this document carefully. You may obtain a paper copy of this Notice upon request.

Consent to communicate PHI

To ensure the protection of your health information and to remain in compliance with HIPAA regulations, Laureate providers and staff ensure to only communicate directly with our patients regarding their health information.  If you’d like to designate other family members or close friends to have the ability to communicate with us regarding your health information, please fill out this form and submit to your practice location manager. 

Medical Information Release  

To request that medical information about you be sent to another physician, your employer or another entity, this form must be completed and signed. This allows Laureate Medical Group to release or obtain protected medical information on your behalf.

Sleep Medicine Questionnaire

All new patients of the Sleep Medicine Practice must complete the above questionnaire prior to his/her scheduled appointment.

Voicemail Consent

To ensure the protection of your health information and to remain in compliance with HIPAA regulations, Laureate providers and staff will not leave detailed voicemails for patients containing health information.  If you would like us to leave voicemails for you regarding your sensitive health information, please fill out the below form and submit to your practice location manager


Forms Completion Fees

Our practice receives many requests to complete various patient forms such as insurance, disability, FMLA, and handicapped parking. Completion of these forms requires medical expertise and a review of medical record documentation. For this reason, a fee based on complexity and length of the forms will be collected prior to releasing the form. It is the patient's responsibility to complete his/her portion of the form and submit it to the requesting party.

Please refer to the fees indicated for applicable requests. If you mail the form to us, please make sure that you send payment with your request. No forms will be completed prior to payment of fees. Note that if you have the form completed at the time of an office visit, there is no fee.

Fee: $35  Free if completed at time of an Office Visit with Physician
  • Nursing home entrance form
  • Adoption forms
  • Disability forms
  • Assisted living forms
  • FMLA
  • School Physical Education Forms
  • Pre-Operative Forms
Fee: $40  
  • Returned Checks (unpaid by your bank)
Medical record requests are priced individually. Please call our Medical Records Department to determine your cost.

Please note:
  • Charges are not billable to your insurance provider and are your responsibility. 
  • All fees must be paid before your next appointment with one of our providers.