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 form is completed, the form may be sent to us by a secure FAX portal, emailed to our secure account using a password-protected PDF at the sole risk of the patient, or printed out and brought to your appointment.  To receive access codes for the secure FAX portal or more information on submitting a password-protected document, contact us at 765-204-1122.

DOCUMENTS TO READ

Welcome Letter

Welcome! You are an important part of the Coze Health Medical team. We believe in empowering our patients for optimizing healthy outcomes.

HIPAA

The HIPAA Privacy Rule assures that your health information is properly protected while allowing health information to provide and promote high quality health care.

Informed Consent

Informed consent policy is your right to be presented with sufficient information to make a decision about giving  consent to a treatment or procedure.

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

History

Before your first 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.

Release of Info

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

PRACTICE INFORMATION​

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

COMMUNICATION

PARTICIPATING INSURANCE

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©2019 by Coze Health Medical LLC