Forms

Download
Membership Agreement
This is the contract that you will be agreeing to if you decide to join this office.
2020 Membership Agreement_with ExhibitA_
Microsoft Word Document 51.5 KB

  

Download
Hearthside Health History Form- Please feel free to print and fill out, however we will review all of this at your first visit.
Hearthside_new_patient_history_form_upda
Microsoft Word Document 470.5 KB

Download
Privacy Notice- You do not need to print. When you sign up, it will ask that you have reviewed this. Please review the document and click YES during registration.
Hearthside Notice of Privacy.docx
Microsoft Word Document 42.5 KB

Download
Hearthside Record Release Authorization, Word document
This is a release of information to receive previous records, or disclose records to another practice. You may submit a release of records to your previous provider OR with us and we can submit that release in order to obtain your medical records for review.
ROIsimplified.doc
Microsoft Word Document 128.5 KB
Download
Hearthside Record Release Authorization, PDF form
This is a release of information to receive previous records, or disclose records to another practice.
ROIsimplified.pdf
Adobe Acrobat Document 95.3 KB