- Privacy Notice (HIPAA)
- Medical Records Request - Requests will only be completed if all sections of the request form are filled out.
If you cannot access the forms above, click on the icon below to download the necessary software.
Please sign in to our patient portal to complete medical forms at least 24 hours prior to your visit with us. This will help to expedite the registration process. Please be sure to document your complete medical history when you fill out our forms. It is very important that you tell us about all medications and vitamins that you are taking with the doses and frequency that you take them, all of the doctors/medical specialists that you see regularly, and all past surgeries that you have had.
A pdf version of our Patient Privacy Notice (HIPAA) is available for download on this page for your records. You will need to download a pdf viewer in order to view the form; if needed, please download Adobe reader.
Medical records are available upon request. Patients, please download and fill out the Record Request form and fax to 201-445-7471 or email to firstname.lastname@example.org. For inquiries regarding previously submitted requests from a patient or a doctor, please call extension 183. For inquiries regarding legal requests, please call extension 114.