Common medical forms are available to patients before their appointment. Select a form using the menu. Downloadable, online fillable versions are available below. Once the forms are completed, you may fax the form to us at 765-205-8322.  You may transfer the completed documents using our online telemedicine portal by appointment (15 minutes before your scheduled appointment), mail the forms to 156 Sagamore Pkwy W. , Ste A, West Lafayette, IN 47906, deliver to the secure drop box located in the foyer at our office (open M-T-Th-F from 9-5 pm, and W 9-12), or print out and bring to your in-office appointment.  

DOCUMENTS TO READ

Privacy & Consent

The HIPAA Privacy Rule concerns protection of your health information.  Informed consent states your rights to giving  consent to a treatment or procedure.

Telehealth

We offer video visits for healthcare and behavioral health. Patients can use a computer with Chrome browser, or a cell phone using Wi-Fi/3g with Safari, Chrome or Samsung. 

Purdue HealthSync

Employees who use Purdue insurance may have received a letter about a PCP. Please take a moment to read our letter for our patients who come from Purdue.

Privacy Practices

The HIPAA Privacy Rule protects all your identifiable health information held by us or a business associate, whether it is electronic, paper, or oral.

DOCUMENTS TO COMPLETE

New Patient

Before your initial appointment, complete the thorough health history form. This form takes about 20-30 minutes to complete.

Communication

On your initial appointment, please complete this form that explains how you would like us to reach you for appointment reminders, lab results, and sharing of health information with relatives and others.

Acknowledgement

Each year, you will need to sign this mandatory form and also before your first appointment. This form states that you read the HIPAA and Informed Consent policies. For digital signatures, include (digital signature).

Release of Info

Patients often have multiple doctors. This form gives us permission to receive health records from previous doctors. You elect which information and from whom.

OTHER FORMS (requested by provider)

Current Symptoms

Before any telemedicine appointment after your first appointment, please complete this one page form that describes how you feel.

Preventive Service

Please complete this form for a preventive service visit. Often, these are your annual wellness visit, but occasionally your provider may request this form.

Depression

We request that certain patients complete this form that describes their level of happiness over the past two weeks. Use this form for telemedicine visits.

Anxiety/Stress

We request that certain patients complete this form that describes the sense of well being over the past two weeks. Use this form for telemedicine visits.

Lifestyle Medicine Intake

PRACTICE INFORMATION​

Clinic: 156 Sagamore Parkway W. Ste A in West Lafayette, Indiana

COMMUNICATION

PARTICIPATING INSURANCE

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©2021 by Coze Health Medical LLC