FORMS

We are excited to offer new HIPAA-compliant online forms to help manage the details that keep your health information secure. Select the form you need and complete online. The submit button will send your information securely to a member of your care team (if you have an urgent matter, call 765-204-1122, or an emergency, call 911).  Please, when uploading copies of your identification or insurance cards, pease select medium quality png, jpg, or pdf (under 5 Mb).

NEW PATIENT INTAKE

Our physician's review your intake form thoroughly. Please take time to answer the questions about your health history, family health history, and lifestyle questions.  

Iris, Concierge Support

MAKE A PAYMENT

Pay for your services by using the convenient online payment tool. Simply list your name, invoice number, and/or date of service. Works for HSA, FSA, and all major credit cards.

Kristen, Billing Support

ESTABLISHED PATIENT

Please complete this simple form each year to agree to the terms of our informed consent, HIPAA Privacy Policy, and Group Class. A concierge support person will alert you if you need to complete this form. (IC-HIPAA)

Iris, Concierge Support

NEW DIETITIAN INTAKE

Our certified lifestyle medicine dietitian will review your intake form before your first session. Please take time to answer the questions honestly, and prepare for a journey of good health.

Jane Gooder, RD

MEDICAL RECORDS

Please complete this simple form for each medical record request. You will need your previous or referring physician's name, facility name, and fax number. 

Iris, Concierge Support

ANNUAL SCREENING

Each year, we request you complete a health screening about personal habits and wellbeing. Your answers are strictly confidential. A concierge support person will alert you if you need to complete this form. (TAM)

Iris, Concierge Support

UPLOAD FORMS

This new tool allows patients to transfer documents to any Coze Health Medical LLC provider. Please limit your documents to 6 and keep the file size to under 25 Mb.

Iris, Concierge Support

COMMUNICATION FORM

We request each patient have an active communication form on file. Please take time to select your preferences for appointment reminder, how to reach you, and next of kin. 

Kristen, Compliance

WELL-BEING SCREENING

Please complete this screening if requested by your provider or concierge support person. This screening is done annually as well as at intermittent visits. Your answers are strictly confidential. (PHQ9, GAD7)

Iris, Concierge Support

PRACTICE INFORMATION​

COMMUNICATION

  • Facebook Social Icon

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

PARTICIPATING INSURANCE

Employee Plans LLC

Medishare

©2021 by Coze Health Medical LLC