Patient Forms

For your convenience, please print and fill out all applicable forms and present them at check in when you arrive for your first visit.

 

Financial Responsibility
Financial Agreement and Assignment of Benefits
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Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
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New Patient Information
New patient demographic and insurance information.
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Records Release
Authorization for Release of Health Information (Including Alcohol/Drug Treatment and Mental Health Information) and Confidential HIV/AIDS related Information. DOH-5032.
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Contact Preferences
Indicate ways that GLPP may communicate information with you.
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Other Resources