SIMMONS CLINIC FAMILY MEDICINE
  • Home
  • COVID-19
  • Services
  • Patient Center
  • About
  • Contact
  • Pay Online

Patient Center

Patient Forms

​Patient Registration Forms & Privacy Notices
 
If you are a new patient, please fill out the registration forms listed below in advance of your appointment to assist the staff in making sure that we have all the information necessary to provide you with quality care and treatment. Please bring the completed forms with you to your appointment.
 
Registration Forms

  • New Patient Packet (Everything a New Patient needs to get started)
  • Medical Records Release (If you need us to request records from another doctor)
  • ​Patient Consent Form (Just your consent to treatment)
  • Contact Method Release (Grab this and tell us everything that may have changed, i.e., email, phone, address, etc.)
  • HIPAA Acknowledgment and Consent
  • HIPAA Family Authorization​
Picture
Patient Rights & Responsibilities
 
We respect our patients’ dignity and pride. This document will explain your patient rights and responsibilities. It is part of your patient registration and is an important part of your health care plan.
 
Privacy Notices
 
This privacy notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
 
Notice of Privacy Practices (provided for you at your first visit
These forms require Adobe Reader. If you do not have Adobe Reader, you may download it free here:

​

Back   Top   Home

YOUR EXPERIENCE IS OUR GUARANTEE

SIMMONS CLINIC
100 East Cahaba Avenue
Liniden, AL. 36748
Phone: (334) 295-0170
Fax: (334) 295-2275
Terms & Conditions  |  Privacy Policy  |  Social Media Policy  |  Acceptable Use Policy  |  Accessibility  |  Responsible Disclosure
Copyright © 2018 Simmons Clinic; All rights reserved
Powered by Create your own unique website with customizable templates.
  • Home
  • COVID-19
  • Services
  • Patient Center
  • About
  • Contact
  • Pay Online