Forms

Patient Information Sheet (Click Here)

New patient form

This form is required of all patients 1) provides contact information necessary to reach the patient by phone or mail 2) authorizes the practice to release health information required by health insurance companies listed and 3) authorizes us to bill insurance for visits and/or collect patient responsibility for billed charges at the time of service.

Financial Policy (Click Here)

New patient form

This form explains the billing process, practice obligations and patient obligations related to payment for medical services. Fees for returned checks, missed appointments and past due accounts turned to collection/tracking are identified. This form stresses the importance of 1) updating insurance information; 2) updating contact information; and 3) taking a proactive role in the payment of claims.

Health History (Click Here)

New patient form

This form gathers past medical history on new patients or patients who have not been in the office recently. This past medical history includes family illness, past and current medication, surgeries and selected procedures as well as social activities with risk factors.

Protected Health Information Consent (Click Here) 

New patient form

This form allows Sparks Family Medicine to call lab results to a phone number provided by the patient. Patients who do not choose to allow lab results to be called to them will be asked to schedule an appointment to be informed of lab results, (even if these results are normal).

Patient Acknowledgement of Privacy Practices (Click Here)

New patient form

Notice of Privacy Practices (Click Here)

The Patient Acknowledgement of Privacy Practices documents the patient’s receipt of the Notice of Privacy Practices as required by HIPAA. Only the Patient Acknowledgement form needs to be included in new patient paperwork.

 

Patient Rights and Responsibilities (Click Here) 

New patient form

This form identifies expectations that patients should have for Sparks Family Medicine as well as the expectations that Sparks Family Medicine has for its patients.

 

Supplement Notification Form (Click Here) 

New patient form

This form provides information regarding supplements and supplement sales at Sparks Family Medicine. The information includes the distinctions between a drug and a supplement, the criteria Sparks Family Medicine uses for choosing the supplements offered in the practice, and the potential difference between supplements at Sparks Family Medicine and other sources. Please note that patients are under no obligation to purchase nutritional supplements.

 

Long Term Controlled Substances Notice (Click Here) 

New patient form

This form provides Sparks Family Medicine’s expectations for patients to access controlled substances. The form provides specific terms regarding receiving controlled substances from a Sparks Family Medicine provider that, if not followed, will result in the patient being dismissed from the practice.

 

Patient Office Visit Form (Click Here)

New and returning patient form

This form is recommended for the patient to help organize the patient’s office visit. The form can be completed prior to the visit to identify the patient’s office visit objectives to make sure that needed or requested refills, referrals and complaints are addressed by the provider. The form also provides a section for the patient to make notes about their visit. As all of the information on this form is entered into SFM’s electronic medical record (other than patient notes), the patient will retain this form after their visit.

 

Medical Records Release #1 (Click Here)

New patient form (Optional)

Completion of this form is necessary to request a patient’s medical records from another health care provider. A fax number for the health care provider’s office is required. Patients can limit the type of health care information requested or select “All Records.” Medical Records Release #2 should be used to request that Sparks Family Medicine transfer your records to another health care provider.

 

Medical Records Release #2 (Click Here)

This form will allow you to request that your records be transferred to another health care provider. Patients can limit the type of health care information requested or select “All Records.”

 

State Specific Advance Directives, AARP (Click Here)

This website provides a drop down menu for state specific Advance Directives forms. Advance Directives provide guidance to your loved ones and health care professionals regarding your health choices.

 

Nevada Living Will Lock Box (Click Here)

This form provided by the Nevada Secretary of State’s office provides information and resources regarding Advance Directives, including the Living Will Lockbox program that provides a virtual lockbox for Advance Directives, living wills, and “do not resuscitate” orders.