The following Conner Clinic patient forms are for new and established patients (labeled below).

Established patients are asked to complete some of the following forms on an annual basis as required by HIPAA. This is asked of all patients at their first visit of the year to the office.

Please complete the forms below and bring a copy of your insurance card at your first visit to the office. We look forward to seeing you.

Demographic and Financial Agreement
Please complete the following form with all applicable information. If you are a parent filling out the form on behalf of your child, please be sure to list a responsible party. At the bottom of the page you will find our financial agreement.
Patient-Demographics-and-Finance
Patient-Demographics-and-Finance-Spanish

Friends and Family Form
This form allows the office staff to contact you via phone, email, or through a family member in regards to lab/radiology results, medical concerns, or financial information. When completing this form, please check what type of information and who can receive the information. Also, please sign the form at the bottom of the page.
HIPAA-Friends-and-Family
HIPAA-Friends-and-Family-spanish

HIPAA Form/Agreement
This form is for your information only. The agreement outlines the rights you have as a patient to keep your information private. The clinic holds the right to disclose information in certain circumstances, the agreement describes the few situations in which disclosure is permitted. The form listed below states that you have received the agreement and requires only the patient’s name, address and signature of responsible party (patient or parent).
HIPAA-Receipt-of-Notice-of-Practice-Privacy
HIPAA-Receipt-of-Notice-of-Practice-Privacy-spanish

Transfer of Medical Records
Please complete the following form to the best of your ability. The most important information needed is the top portion and a signature. As a patient, if you would like records sent to or from our practice, please fill out the middle portion with as much information as possible.
Medical Records PHI
Medical Records PHI – Spanish

Patient History
The following form is simply to provide the physicians with as much information as possible before your first visit. Please complete to the best of your ability.
Patient Health History Form
Patient-Health-History-Form-Spanish

Physical Exam Informed Consent
Physical_Health_Reform_ABN_ConnerClinic

 

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