Patient Forms

Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.

Patient Forms

Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente

Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Additional Patient Forms

New Patient Forms

Click here if you are seeing:

Rakesh Patel, DO
Nadia Younus, PA
Shannon Gregorek, APN
Sanket Shah, PA
Radha Bernander, PA-C
Veena Warwe, MD
Preeya Raghu, MD
Vivienne Leyco-Policarpio, MD
Noor Yazdanie, MD

Click here if you are 18+ seeing:

Paul Butler, MD
Alyssa Sanchez, PA-C

Click here if you are 13-17 seeing:

Paul Butler, MD

Click here if you are under 13 seeing:

Paul Butler, MD

Informed Consent Form for Therapy Services

Office Policies

Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)

Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)

HIPAA Privacy Notice