Forms


All forms are provided as PDF's. Please locate and install a readily available free PDF Reader if you are having trouble viewing the form. Please feel free to contact us with any questions regarding the forms.

Appointment Related Forms:

New Patient:

While your insurance may not require it, it may be wise to gain a referral to our practice by your primary provider. The referral can be provided to your insurance, which only adds more pressure on them to reimburse at appropriate levels. Suggested referral verbiage that you can provide your provider follows and we have a referral form as well:

XXXXX (patient name and DOB) has or is suspected to have a mitochondrial, metabolic, or other inherited disorder that requires a specialist in those fields. We have referred this patient to Dr Kendall (NPI# 1881658300) at VMP who is a biochemical geneticist recognized as a leader in and is one of only a handful of specialists in the US who are focused and knowledgeable in this field. There are no such specialists within a reasonable radius or who have openings without a long waiting list. Please remember that not all geneticists are the same nor have the skills as Dr Kendall has to properly diagnose or treat this patient.

Please contact us for a strong letter that you can provide your insurance that requests in network benefits. Many are being granted in network benefits which increases your reimbursement. Please remember that depending on your insurance company and even without in network benefits many plans reimburse some amount. 

Follow up Appointment:

    • Follow up Questionnaire
    • General Contact Information - for updating who is to receive notes or to update your contact info
    • Please contact us for a In Network Request Letter which can be filled in by you and sent directly to your insurance to help increase your reimbursement.

Travel Related Forms:

The following form provides lodging, travel, fun things to do locally, restaurant tips, and directions to our clinic: 

Medical Record Related Forms:

Authorization to Release Medical Records to VMP from your past provider: The following form is helpful to use when you are gathering the records to supply to us.
 
Authorization to Release Medical Records From VMP to another office: Please understand we take releasing medical records very seriously in today's environment and their release has become a very complex process due to all the rules and regulations that are involved.  We prefer patients release their own records as they see a need. Records for those patients seen within 14 months are supplied for free to the patient and for a $25 fee for each 3rd party.  If the patient has not been seen within 14 months there is a charge of $25 for providing records to the patient and $50 to each 3rd party. It can take a week or more to release records to 3rd parties or a day or two when releasing to the patient. 
 
Correction/Amendment of PHIOnce a clinical note is released, any further changes or modifications requires the note to be identified as AMENDED along with identifying what has changed. If a patient wishes to change their note we require this form be filled out and returned to us.