Authorization for Release of Medical Records Form


New Patient Letter

Patient Information Form

Patient History Form

Review of Systems

Cancellation and No Show Policy



It is the goal of our staff to accommodate as many requests as possible in a timely manner. In order for us to do so, please be aware of the following policies regarding any requested letters or FMLA, Short and Long Term disability, and any other paperwork that may be required or requested.

  1. Blank forms will not be accepted. The patient/employee information sections of the form must be completed and signed prior to drop off.
  2. Turnaround time for paperwork completion is 10-12 business days. Forms will not be completed on the day presented to the office. Letters that are needed will not be done the day it is requested. It is the patient’s responsibility to bring in paperwork in a timely manner before the requested due date from your employer, insurance company, or school.
  3. Forms will be held at the office for patients to pick up once completed. It is the patient’s responsibility to provide the completed forms to their insurance company, employers, schools, etc. As a courtesy, if you would like us to fax these once completed, please ask the Medical Records/Compliance Coordinator and provide the appropriate fax number.

Please note that the paperwork will reflect the medical necessary time off and or accompanying conditions that are noted with the patient. All forms or requests are at our physicians’ discretion.
If you have any questions, please feel free to speak with the Medical Records/Compliance Coordinator at the time of check out or call 937-312-6531.