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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

  • Medical/Personal History: necessary for your Beacon Internal Medicine Physician
  • Review of Systems for Physical Exam: necessary for your Beacon Internal Medicine Physician
  • Patient Registration: provides us with your basic demographic and insurance information so that we can contact you as needed and bill your insurance appropriately. Please sign the bottom of this form and make sure to include proper subscriber information.
  • Financial Policy: This form is needed for both Beacon Internal Medicine and Beacon Rheumatology New Patients and it is to help you understand how and why billing is done. Please sign the bottom of the form as acknowledgement that you have read the information.
  • Patient Consent: This form is needed for both Beacon Internal Medicine and Beacon Rheumatology New Patients and it allows us to treat you.
  • HIPAA Acknowledgement and Disclosure Consent
  • Authorization for Release of Protected Health Information: offers you the opportunity to allow for your medical records to be released from Beacon Internal Medicine to parties that you have designated on the form or for your medical records to be released from parties that you have designated on the form to Beacon Internal Medicine.

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.

Patient Rights & Responsibilities

Derechos y Responsabilidades del Paciente

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.

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