Patient Resources
Find the forms and information you may need before, during or after your visit with Harbor Physicians.
New Patient Forms
Choose the packet that works best for you and complete it before your first appointment.
New Patient Packet
Includes the forms and instructions needed for new patients who prefer to complete their paperwork in English.
Bilingual New Patient Packet
Includes the same new patient information with English and Spanish presented together for easier review.
Please bring: your completed packet, photo identification, insurance card and a current medication list to your appointment.
Medical Records
Use this form to authorize Harbor Physicians to request records from another provider or to release records when needed.
Medical Records Release Form
Request or authorize the transfer of medical records
Complete the patient information, requested records, purpose and signature sections of the form. Harbor Physicians will complete the provider or facility section to help ensure the authorization is processed correctly.
- 1. Open and download the form.
- 2. Complete and sign the patient sections.
- 3. Return the completed form to Harbor Physicians.
Important: Please do not complete the provider or facility section. Our office will complete that portion so the authorization can be processed correctly.
Your Privacy and Health Information
Review your privacy rights and use the appropriate form when authorizing Harbor Physicians to discuss or release protected health information.
HIPAA Authorization
Use this form to identify a family member, caregiver or other person Harbor Physicians may speak with or release protected health information to.
Notice of Privacy Practices
Review how Harbor Physicians may use and disclose protected health information for treatment, payment and healthcare operations, along with your privacy rights.
Please protect your information: do not send Social Security numbers, medical records or other sensitive health information through regular email.
Telehealth Consent
Complete this consent form before a scheduled telehealth appointment so your provider can deliver care by video, audio or other secure electronic communication when appropriate.
Telehealth Consent Form
This form explains how telehealth may be used for evaluation, diagnosis, treatment and follow-up care. Your provider may still recommend an in-person visit when medically necessary.
- Complete the consent before your scheduled virtual appointment.
- Review the privacy, technology and examination limitations explained in the form.
- Your provider may recommend an in-person visit when it is appropriate for your care.
Telehealth is not for emergencies. Call 911 or go to the nearest emergency room for urgent or life-threatening symptoms.
Financial and Patient Policies
Review important information about insurance, payment responsibilities, patient conduct and the standards that support respectful, safe and effective care.
Financial Policy
Review your responsibilities for insurance information, referral requirements, copayments, deductibles, coinsurance, unpaid balances and assignment of insurance benefits to Harbor Physicians.
Patient Conduct Policy
Review expectations for respectful communication, patient safety, cooperation with care plans and office policies, and conduct that may affect continuation of care.
Please review before signing: contact our office if you have questions about financial responsibility, office policies or any acknowledgment before submitting your completed form.
Formularios en Español
Estos documentos están disponibles en inglés y español para facilitar su revisión y completar la información correspondiente.
Autorización HIPAA
Autoriza a Harbor Physicians a comunicarse con una persona designada o divulgar información médica protegida.
Divulgación de Registros Médicos
Autoriza la solicitud, transferencia o divulgación de expedientes médicos según sea necesario.
Política Financiera
Explica responsabilidades de seguro, copagos, saldos del paciente y asignación de beneficios.
Acuerdo de Conducta
Describe las expectativas de conducta respetuosa, cooperación y seguridad dentro de la práctica.
Consentimiento para Telemedicina
Requerido antes de una visita virtual o consulta médica por telemedicina.
Estimado de Buena Fe
Información sobre estimados de costos para ciertos pacientes o servicios cuando corresponda.
¿Necesita ayuda? Llame a Harbor Physicians al (904) 368-6809 si tiene preguntas sobre cuál formulario debe completar.
Important Information
Please review these reminders before completing or returning forms to Harbor Physicians.
Need Help Choosing the Right Document?
Contact our office if you are unsure which form to complete or need help accessing, downloading or returning a document.
Saturday appointments are available by appointment only.