Patient & Provider Forms

 

Here at T² Family Practice, we like to save you time and run our office as efficiently as possible. To do so, we’ve provided our patient forms below for you to download and fill out at your convenience. Please print out the forms instructed by our staff, fill it out, and bring it with you to your next appointment.

 

• Notice of Privacy Practices [PDF]
• Receipt of Privacy Practices Notice [PDF]
• Financial Policy [PDF]
• Authorization for Medical Records Release [PDF]
  
• No Show Policy [PDF]
• Authorization for Disclosure of Protected Health Information [PDF]
• Patient Registration Form [PDF]
• Medical History [PDF]
• Request for Confidential Electronic Communications [PDF]

Patient Portal

You’ll need a username and password. Please contact the office to get set up for access.

 

Our Patient Portal Gives You The Ability To:

• View educational documents and clinical messages
• Access patient questionnaires
• Request appointments, demographic and guarantor changes
• Update insurance changes
• Request a copy of your medical records
• Access your medical records

Insurance & Billing

At the time of your appointment, all insurance copayments and deductibles are due. All patients are expected to pay in full at the time of service. We will collect your payment before you see the doctors. T² Family Practice accepts cash, checks, Visa or MasterCard as payment.

 

We accept most major insurance plans. Please check with your insurance provider to confirm that T² Family Practice is on your insurance plan.

 

New Patients

In addition to the completed paperwork for new patients, we ask that you arrive ahead of your scheduled appointment time to assure all the necessary forms are properly filled out. Please also bring your insurance card, a photo ID, and your copay, if necessary.

 

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.