Forms and Documents

For your convenience, the forms we use in our practice are available in PDF format here on our website. We strongly urge you to print out and complete these forms before your appointment. By doing so at your leisure rather than hurriedly in our waiting room, you can make sure your records in our office are as accurate as possible. By completing the forms in advance, you will also expedite the registration process and reduce your time in the waiting room. Please print out, complete and mail, fax or bring these forms to your visit. If you cannot print these forms at home, they will be provided to you upon check-in.

To help you get ready for your next appointment, we have created this guide to the forms we need. Please reference this table to determine which forms to print then select and print them below.

If you are a: Print and Complete:
New Patient
New Patient Information Packet
New Patient (under 18 years old)
New Patient Information Packet
- PLUS -
Adolescent Questionnaire
New Patient with Medicare Insurance
New Patient Information Packet
- PLUS -
Medicare ABN

If you are a: Print and Complete:
Returning Patient who:
1. Does NOT need to update information
    - OR -
2. HAS been seen by this office within the past year
Medical Services Waiver
Returning Patient who:
1. NEEDS to update information
    - OR -
2. Has NOT updated an information form within the past year
    - OR -
3. Has NOT been seen by this office within the past year
Patient Information Update
- PLUS -
Medical Services Waiver
- PLUS -
Authorization for Release of
Protected Health Information
Returning Patient with Medicare Insurance
Patient Information Update
if necessary (see above)
- PLUS -
Medicare ABN

Patient Forms (click on the icons on left)

New Patient Information Packet
Please print, complete, and mail, fax or bring these forms with you to your first visit!

New Patient Packet Includes:
Patient Registration form, Basic Health Questionnaire, Detailed Health History, Medical Services Waiver, Authorization for Release of Protected Health Information and Medical Records Release Form.
Patient Registration Form Patient Information Update
Please print, complete and mail, fax or bring this form with you if you have any information that needs to be updated in our system, or if you have not been to the office within the past 12 months.

Information updates include:
Any changes to name, address, phone numbers, insurance carriers, employer, emergency contact numbers.
Medical Services Waiver Form
Medical Services Waiver
Adolescent Questionnaire Adolescent Questionnaire (18 years old or younger)
Please print, complete, and mail, fax or bring this questionnaire to your visit. You should be comfortable to discuss your answers with Dr. Thaxton and know that your conversations will be kept strictly confidential.
Medicare ABN Medicare Advance Beneficiary Notice (ABN)
Medicare mandates that all patients with Medicare coverage complete an ABN. This form will become a part of your medical record. Please print, complete, and mail, fax or bring this form with you to every visit in our office. Failure to complete an ABN for each visit could result in charges you may be responsible to pay to our office.
Detailed Health History Detailed Health History
This is a complete detailed health history form with patient information. If requested by the doctor's office, please print and complete this form and get it back to us prior to your visit.
Consent for Release and Use of Protected Health Information
This form is used to acknowledge receipt of the Notice of Privacy Practices and to give consent to release and use confidential information.


For Your Information

HIPAA Notice Privacy Practices Notice
Download this form for a copy of the HIPAA privacy act notice. Copies of this form are also available elsewhere on our website and in our office.
Records Release Medical Records Release
If you are a new patient and are transferring from another practice, please download this form and mail or fax it to your previous provider.
Records Release Financial Policy
Your clear understanding of our Financial Policy is important to our professional relationship. Please download this document and read it carefully.
Records Release Office Visit Checklist
We understand a visit to the doctor can be stressful We suggest you print out this checklist prior to your next appointment and use it to make notes to remind you what to discuss with Dr. Thaxton.