Patient Forms

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.

Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.

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.

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

This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.

Information about language assistance services and Privia's Notice of Nondiscrimination.