Patient Resources
Forms and information for your care
Access patient forms including new patient packets, medical records forms, HIPAA documents, telehealth consent forms and important office policies. Choose the form you need below, then download, complete and return it as directed.
Completing forms on a phone or tablet? You may need to download the PDF to your device before completing and saving it. A desktop or laptop computer may provide the best experience.
New Patient Forms
Choose the packet that works best for you and complete it before your first appointment.
New Patient Packet
English
Use this packet if you prefer all patient forms and instructions in English.
New Patient Packet
English & Español
Use this bilingual packet if you prefer each section in both English and Spanish.
Medical Records
Use this form to authorize Harbor Physicians to request records from a previous provider or to release records as needed for your care.
Medical Records Release Form
Request or authorize the transfer of medical records
Complete the patient information, requested records, purpose and signature portions of the form. Harbor Physicians will complete the provider or facility section to help ensure accurate processing.
Your Privacy and Health Information
Review how your health information is protected and use the appropriate form when authorizing Harbor Physicians to communicate with another person about your care.
HIPAA Authorization
Release of Protected Health Information
Use this form to identify a family member, caregiver or other person Harbor Physicians may speak with or release protected health information to.
- Designate an authorized person.
- Choose not to authorize anyone.
- Authorize discussion of appointments, billing and records.
Notice of Privacy Practices
HIPAA Notice and Patient Rights
Review how Harbor Physicians may use and disclose protected health information for treatment, payment and healthcare operations.
- Learn how your health information may be used.
- Review your privacy rights.
- Understand Harbor Physicians’ responsibilities.
Telehealth Consent
Complete the consent form before a scheduled telehealth appointment so your provider can deliver care through video, audio or secure electronic communication when appropriate.
Telehealth Consent Form
Required for telehealth visits
This form explains how telehealth may be used for evaluation, diagnosis, treatment and follow-up care. Your provider may still require an in-person visit when medically necessary.
Financial and Patient Policies
Review important information about insurance, payments, patient responsibilities, respectful communication and the expectations that support safe and effective care.
Financial Policy
Assignment of Benefits
Review your responsibilities for insurance information, copayments, deductibles, coinsurance, unpaid balances and payment of benefits to Harbor Physicians.
- Insurance and referral requirements
- Copayments and patient balances
- Returned payments and no-show fees
- Assignment of insurance benefits
Patient Conduct Policy
Conduct and Discharge Acknowledgment
Review the standards that support respectful communication, patient safety, cooperation with care plans and a professional clinical environment.
- Respectful communication with staff and providers
- Cooperation with treatment plans and office policies
- Safe behavior within the practice
- Actions that may affect continuation of care
Formularios en Español
Los siguientes documentos están disponibles en inglés y español para facilitar su revisión y completar la información correspondiente.
Autorización HIPAA
Inglés y Español
Autoriza a Harbor Physicians a comunicarse con una persona designada o divulgar información médica protegida.
Abrir FormularioDivulgación de Registros Médicos
Inglés y Español
Autoriza la solicitud, transferencia o divulgación de expedientes médicos según sea necesario.
Abrir FormularioPolítica Financiera
Inglés y Español
Explica responsabilidades de seguro, copagos, saldos del paciente y asignación de beneficios.
Abrir PolíticaAcuerdo de Conducta
Inglés y Español
Describe las expectativas de conducta respetuosa, cooperación y seguridad dentro de la práctica.
Abrir AcuerdoConsentimiento para Telemedicina
Inglés y Español
Requerido antes de una visita virtual o consulta médica por telemedicina.
Abrir ConsentimientoEstimado de Buena Fe
Inglés y Español
Información sobre estimados de costos para ciertos pacientes o servicios cuando corresponda.
Abrir DocumentoImportant Information
Please review these reminders before completing, emailing or returning patient forms to Harbor Physicians.
Form and Safety Reminders
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Reviewed During Business Hours Forms and messages are reviewed during regular office hours and may not receive an immediate response.
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Protect Sensitive Information Do not send Social Security numbers, full medical records, insurance cards or sensitive health information through regular email.
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Complete Applicable Sections Review each form carefully, complete all applicable sections and sign wherever required before returning it.
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Forms Are Not for Emergencies Call 911 or go to the nearest emergency room for urgent, severe or life-threatening symptoms.