Patient forms

We have provided links to our more commonly completed forms below. We ask new patients to complete the Patient Registration and Patient Health History forms prior to arriving for their appointment.

  1. New Patient Registration Form

Patients will need to fill out an admission form with basic information about them and their medical history. In addition, they will need to provide contact information. 

  1. No Show Fee Acknowledgement Form

It is an acknowledgment form and by signing this form the patient acknowledges that he/she has reviewed the No Show Fee Policy. It states that the patient agrees to pay

Gerid Medical Consultants a fee of $50 in the event the patient is unable to make an appointment and do not notify the clinic in advance.

  1. Health History Form

It is a document with history containing baseline information and records of past and present health issues. It should include a medication section, lists of hospitalizations and ER visits, medical tests done with results, list of past and present doctors and immunizations.

  1. Request to Disclose/Release Protected Health Information Form

By completing this form, patient is authorizing the provider to use or disclose his/her protected health information, as defined by law.

  1. Medicare Wellness Visit Acknowledgement Form

This form is to indicate which Medicare / Medicare Advantage Wellness Visit you are

requesting for today. An explanation of what is included in each visit will be provided to you upon request

  1. Advance Beneficiary Notice Form

The ABN allows you to decide whether to get the care in question and to accept financial responsibility for the service (pay for the service out-of-pocket) if Medicare denies payment. The notice must list the reason why the provider believes Medicare will deny payment.