New Patient Registration Form
Please use the pharmacy benefits information, this could be a different card than the medical

Your privacy is important to us. To protect the privacy of your individual health information (Protected Health Information, "PHI") and as part of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), we are required to provide each patient with a Notice of Privacy Practices before or at the time of our healthcare services. We are also required to ask each patient to sign an acknowledgment form specifying receipt of this notice. We ask that you please read the Notice of Privacy Practices and sign below as a receipt of our privacy notice.