Welcome to our Practice!
We are thrilled that you would like to join our family of patients! After reviewing our Notice of Privacy Practices, please fill out the online form below in its entirety. By submitting the form to our office, you agree that all “Digital Signature” fields stand for your official signature. [Note: This online form is HIPAA compliant. All submitted information will be secure and accessible only by our office.]
If you are unable to complete these forms online, please click here for a printable version. You can return the forms to our office in person or fax them to 336.570.3583.
Upon receipt of your forms, our Appointment Coordinator will contact you to set up your first appointment. We look forward to meeting you soon!
Notice of Privacy Practices
The HIPAA Privacy Rule gives individuals a fundamental right to be informed of the privacy practices of their health plans and of most of their health care providers, as well as to be informed of their privacy rights with respect to their personal health information.
Our Notice of Privacy Practices provides a description of our treatment, payment activities, and healthcare operations; of the uses and disclosures we may make of your protected health information; and of other important matters about your protected health information. We encourage you to read it carefully and completely before completing our New Patient Forms.
If you have any questions, please contact our HIPAA Compliance Officer at 150 West Crescent Square Drive, Graham NC 27253; Phone 336.570.3882.