Patient Resources > Patient Forms

Save time in the waiting room. Download and print our patient forms and fill them out at your convenience. Remember to bring the forms with you on your next appointment.

Patient Registration, (1) Page*
Our Patient Registration form is required upon your first visit. This form requires your personal information plus your insurance information. Please print, fill out and bring it with at the time of your appointment.

Health History, (1) Page*
Our Health History form is required upon your first visit. Please answer all of the questions as accurately as possible in order for Dr. Fusi to provide the very best quality care. If you do not understand the quesiton, please ask for assistence. Please print, fill out and bring it with at the time of your appointment.

Financial Policy, (1) Page*
Our Financial Policy form is required upon your first visit. Please carefully read our Financial Policy. Our main concern is to provide you with the best possible care in a convenient, informative and helpful manner. If you have any concerns about our payment policies, please do not hesitate to contact our office staff. Please print, fill out and bring it with at the time of your appointment.

Patient Record of Disclosures, (1) Page*
Our Patient Record of Disclosures form is required upon your first visit. Please carefully read our Financial Policy. The HIPPA privacy rule gives indivuals the right to request a restriction on uses and disclosures of their protected health information. Please print, fill out and bring it with at the time of your appointment.

Notice of Privacy Practices, (8) Pages*
The Notice of Privacy Practices describes how medical information about you may be used and disclosed, and how you can access this information. After your read, please print and sign the Acknowledgement form below.

Acknowledgement of Receipt of Privacy Notice, (1) Page*
Read the above Notice of Privacy Practices. Please print, fill out and bring it with at the time of your appointment.

* All forms are in Adobe format. If you have any problems downloading the forms, please update your free version of Adobe Reader. Click on the Adobe link and follow the instuctions.