Welcome to Kymera Independent Physicians
Wednesday, May 24 2017 @ 05:49 AM MDT

Patient Forms

KYMERA'S PATIENT FORMS REQUIRED FOR THE FIRST APPOINTMENT / VISIT

 

DOWNLOAD THE FORMS HERE

To save you time on the day of your appointment:
Print; fill out at home; bring to your first appointment -- 10 minutes prior.
If not filled out at home please show up at your appointment -- 30 minutes prior.

  • PATIENT & INSURANCE INFORMATION - FORM ( 2 pages)
    • --Patient Information
    • --Guarantor Information (if patient is under 18)
    • --Primary Insurance Information
    • --Secondary Insurance Information
  • MEDICAL RECORDS RELEASE FORM (1 page)
  • PATIENT INITIAL HISTORY - FORM (1 page)
  • NOTICE OF PRIVACY PRACTICES (2 pages) (Please read -- nothing to sign)
  • NEW PATIENT FINANCIAL INFORMATION - FORM (1 page)(Please read -- nothing to sign)
  • PRESCRIPTION REFILL POLICY (1 page)(Please read -- nothing to sign)
  • MEDICARE PATIENT FORM (2 pages)(***Medicare Patients Only***)
  •  PATIENT CONSENT TO THE USE & DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND / OR HEALTH CARE OPERATIONS - FORM (1 page)

 

DOWNLOAD THE FORMS HERE (pdf 7mb) 

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