The signature on File form is the form that patients are asked to sign once at check-in. This form gives us authorization to bill their insurance company and insures their responsibility for co-payments, deductibles etc.

The Approved Participants of Care form gives LO physicians and staff the authorization to discuss a patient’s care with family members and/or other designated people on the list.

• HIPAA Release
• Permission to Treat
• Signature On File 2003
• Approved Participants of Care 2003
• Personal Health History

NOTICE OF PRIVACY PRACTICES