New Patients

    Thank you for choosing our Clinic for your medical needs.  Please be sure to bring to your appointment any medications you are currently taking in their original bottles, any previous medical records you have available and your current insurance card(s).  We will ask you to fill out a records release at your first visit. Please try to arrive approximately 15 minutes earlier than your appointment time in order to take care of paperwork and insurance registration.

    Please print out the following new patient paperwork and bring the completed forms to your first visit.  Please use black ink and print legibly.  You will need Adobe Reader to view the documents.

Patient Registration Form - This form should be presented to the front office on your first appointment at our Clinic.  It asks for information such as your name, date of birth, address and various phone numbers for the Clinic to keep in your records.

Notice of Privacy Practices - This is an informational packet that describes how the Butler County Clinic, P.C. protects your privacy under the HIPAA laws.  It is yours to read.  You do not need to sign anything on this document.

HIPAA (Health Insurance Portability and Accountability Act of 1996) - This form acknowledges that we have provided you with a copy of our privacy policy in compliance with HIPAA laws.

Financial Policy - This form describes our billing policies and guidelines. Please read this form carefully.

Medical Records Release - This form can be filled out to have your records transferred from your previous doctor to our Clinic.  Simply provide us with your last physician's information, return the form to us when you come in.  We will send this form to your previous doctor's practice to obtain your records for our physicians to have on file.

Spanning the Generations. . .

 

For any questions about these forms, please contact our front office at 402-367-3193.