Current list of forms

For your first appointment, print these forms: 1. Initial Evaluation History Sheet, 2. HIPAA and 3. the Financial Payment Policy, fill them in and bring them with you. Thanks. You'll save a lot of time in the waiting area.

United Healthcare Insurance Patients, please use their health questionnaire. United Healthcare requires their subscribers to use their own forms.

You can get a free Adobe document reader here.

Adobe (PDF) versions of the forms:

1. Initial Evaluation History Sheet
2. Notice of Patient Privacy Practices (HIPAA)
3. Financial Payment Policy
4. United Healthcare (PDF) questionnaire.

Microsoft Word (.DOC) versions of the forms:

1. Initial Evaluation History Sheet
2. Notice of Patient Privacy Practices (HIPAA)
3. Financial Payment Policy
4. United Healthcare (.DOC) questionnaire.

Discharge Survey:

Discharge Survey in PDF format
Discharge Survey in Word format

Phone: (410) 229-0055 | Email: info@herefordpt.com
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14 Mt. Carmel Road, Parkton, MD 21120. All rights reserved.

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