Forms

The following are forms that need to be filled prior to our first clinic visit:

Now that I am online, there are a few options for filling out forms. You do it the old fashioned way print it, fill it out, take a picture or scan the signed document and email (pratistha.strong@gmail.com) it to me or fax it to 432-614-2599:

  • Medical Release of Information (I have made this a fillable form. You may have to print this and sign it. Otherwise hospitals and doctor’s offices will not accept this form.)
  • CMS Opt-Out This is only for patients with Medicare. This is a fillable form.(You may have to print this and sign it.)

You can use Google Forms and do the same submission online. At this point I do not have a Medical Release of Information form or the CMS Opt-Out form that is equal to the Google Forms.

  • Medical Release of Information (I have made this a fillable form. You may have to print this and sign it. Otherwise hospitals and doctor’s offices will not accept this form.) This is the same as above.

For return phone visits, it is helpful if I know what symptoms you are having for your visit. Please fill the following form out:

The following are for reference only. You do not need to print this or sign it.