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Fax(703) 707 0949

Patient Forms

You may print, fill out, sign and bring in the appropriate forms to your appointment. The Registration form and HIPAA Contact Preference form are required for ALL patients and on a yearly basis. For patients coming in for a complete physical, please note the forms are different for existing versus new patients.


Practical Information for our Patients

Patient Registration Form - required for ALL new patients and existing patients (once per year)

HIPAA Contact Preference Form  - required for ALL new patients and existing patients(once per year)

Existing Patient History Review Form - required for all existing patients coming in for a complete physical, preoperative examination, or for those who have not been seen in over a year.

New Patient History Review Form - required for all new patients except those coming in for immigration or FAA examinations unless otherwise informed to do so by office staff.

Medicare Health Risk Assessment (HRA) Page 1 form, Page 2 Form, Page 3 Form - for the "Welcome to Medicare" exam AND Medicare's "Annual Wellness Visit" (AWV)

Medicare Letter - letter to Medicare patients (2/24/11) about the changes to care/visits, etc... based on The Affordable Care Act (ACA) of 2010.

Record Release Form

Patient Portal Authorization Form

eMD Patient Portal Instructions

Notice of Privacy Practices (NPP)

Telemedicine Form for non-Medicare Patients and Dr. Gorrelick's Tricare Patients

Telemedicine Form for Medicare and Dr. Eapen's Tricare Patients

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