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Forms

Many of the PDF forms below are supplied to you when you made your appointment but are provided here for backup. If you are having trouble viewing the form, please make sure a readily available free PDF Reader is installed on your device and updated. Please feel free to contact us with any questions regarding the forms.

Appointment Related Forms:

New Patient:

Please contact us an In Network Request Letter that you can provide your insurance which if granted by your insurance will increase any reimbursement. Supplying your insurance with a referral to our practice by your primary provider may provide additional support to the In Network Request even if your insurance may not require a referral. Following is suggested referral verbiage that you can provide your PCP and we have a referral form that you can supply them 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.

Follow up Appointment:

Travel Related Forms:

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

Subscription Sign-up Form:

Fill out and return the Subscription Service form to sign up to have product delivered to you on a schedule you set. Eliminates the risk of running out and the hassle/guesswork of reordering product. 

Medical Record Related Forms:

  • Release Medical Records to VMP - The following form is helpful to use when you are gathering the records to supply to us.
  • Release Medical Records From VMP - releasing records 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 fee mandiated by the state of Georgia for each 3rd party.  If the patient has not been seen within 14 months there is a fee as mandiated by the state of Georgia for providing records to the patient and or any 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 PHI - this form is required on file if there are any changes to our clinical note after it has been released. Once a clinical note is released, any further changes or modifications requires the note to be identified as AMENDED along with identification of what has changed.