New Patient Forms

For all new patients:

Please complete prior to your appointment:

• Authorization To Disclose Protected Health Information (PHI)-Fillable and Printable (to obtain records from your previous provider)

• New Patient Financial Policy

• InterMed Consent to Treat

• Adult Communication Authorization

Additional Forms:

Please complete applicable forms prior to your appointment:

Adult (18+ years old)

• Adult Patient Information Forms

• New Adult Medical History Form

• New Adult Medicare Health Risk Assessment Form (only needed if you have a Medicare Advantage plan*)

Pediatric (17 years old and younger)

• Pediatric Patient Information Forms

• Pediatric Patient Information Communication Authorization

Ob-Gyn

• Gyn Medical History Forms

• Ob Medical History Forms

Established Patient Resources

Forms:

• Acknowledgement of Self-Pay Status Patient Responsibility

• Authorization To Disclose Protected Health Information (PHI)-Fillable and Printable

• Authorization To Disclose Protected Health Information (PHI) for Disability or FMLA – Fillable and Printable

• Maine Health Care Advance Directive

   

• Release of Immunization Records for school, camp, etc. (Pediatric patients)

  
  

Informational:

• Newborn discharge instructions and resources

   

• Teen Resource Packet

• Language Services and Notice of Privacy Practices