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Forms

The key forms (history, follow-up, consents, contact) can be found in your portal account. Please read the welcome letter that we provided in your portal since it will walk you through the appointment process. Accessing forms in your portal allows you to fill them out and submit them online.

The forms provided below for download are provided outside of the portal for your assistance. Please make sure a PDF Reader is installed on your device below downloading. Please feel free to contact us with any questions regarding the forms.

Forms Found In Your ChARM Portal:

  • Patient Consent Form - must be on file for all patients.
  • Telemedicine Consent Form - must be on file if you have a telemedicine appointment.
  • Medicare Patient Consent Form - must be on file if you have Medicare.
  • General Contact Information
  • Privacy Notice
  • New Patient History Questionnaire - adult 
  • New Patient History Questionnaire - child
  • Follow-up Questionnaire - for established patients returning for an appointment. 
  • After Appointment - designed to answer questions that may arise after the appointment.
  • Personal Representative Form - to allow us to discuss issues and make appointments through another person if you are over 18 yrs old.
  • In-Network Request Letter—If this letter is not in your portal, please contact us for it. Once filled out by you, you can send it directly to your insurance to help increase your reimbursement.

Forms for Download:

  • Directions & helpful travel tips - provides lodging, travel, fun things to do locally, restaurant tips, and directions to our clinic
  • Referral Form - can help with insurance reimbursement.
  • Release Medical Records to VMP - 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 mandated by the state of Georgia for each 3rd party.  If the patient has not been seen within 14 months, there is a fee as mandated 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 them 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 require the note to be identified as AMENDED along with identification of what has changed.