Patient Forms

Springfield Market Patient Forms and Resources

Forms

• Patient Registration Form
• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• Verbal Release of Information (English)
• Verbal Release of Information (Español)
• Financial Guidelines for Healthcare Services
• Caregiver Authorization Affidavit
• Massachusetts Temporary Agent Authorization Form
• Notice of Private Practices (English)
• Notice of Private Practices (Español)

Assessments 

• NICHQ Vanderbilt Assessment Scale-Parent
• NICHQ Vanderbilt Assessment Scale-Teacher

Articles

• Suffering from Lower Back Pain by Dr. James Delsie
• Staying Healthy in the Winter by Dr. Gary Gorman
• Understanding Scoliosis by Dr. James Delsie
• Healthy Nutrition in Our Children by Dr. Karolina Ogrodnik
• What is Physiatry? by Troy Chilson, PA-C

Waterbury Market Patient Forms

Waterbury

56 Franklin Street

Behavioral Health

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form

Cardiology

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• No-Show Waiver Form
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms 

Infectious Disease

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Welcome Letter
• New Patient Intake Form
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form
• Meaningful Use Questionnaire

60 Westwood AvenueFranklin Digestive Disease

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form
• 2-Day Prep Mag
• Breath Test Guidelines
• Colyte or Nulytely or Trilyteprep - Clear Liquid Diet - Consent
• Endoscopic Retrograde Cholangiopancreatography (ERCP) Instructions
• Enteroscopy
• Flex Instructions and Consents
• Halfytely Clear Liquid Diet Consent Form
• Halo RFA and EGD or Esophagoscopy Instructions
• Halo RFA Consent Form
• Medicare ABN Form
• Medicare PQRS Data Form
• Miralax Prep - Miralax and Dulcolax
• Moviprep - Clear Liquid Diet - Consent
• Percutaneous Endoscopic Gastronomy (PEG)
• Percutaneous Endoscopic Gastronomy Replacement or Removal
• Pill Cam Instructions - Consents
• Prepopik - Instructions - Consents
• Refusal to Permit Blood Transfusion
• Suprep - Instructions - Consents

95 Scovill StreetFamily Health Center - Pavilion B

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form

Med Pediatrics - Pavilion B

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• Child's Tuberculosis Lead Screening
• Guardian Authorization to Treat Child
• Patient Information Update
• Child's Medical History
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form

133 Scovill StreetFranklin Faculty Practice - Suite 102

• New Patient Welcome Letter
• New Patient Intake Form
• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form
• Meaningful Use Questionnaire

Franklin Pulmonary/Critical Care - Suite 104

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms

Franklin Travel Medicine Clinic - Suite 102

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Welcome Letter
• New Patient Intake Form
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form
• Meaningful Use Questionnaire

Rheumatology - Suite 213

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Welcome Letter
• Insurance & Registration Form
• New Patient Intake Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form 

Franklin Orthopedic Surgeons - Suite 308

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Intake Form
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form 

Franklin Surgical Services - Suite 308

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Intake Form - Dr. J. Alexander Palesty
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form 

140 Grandview Street

Franklin Gastroenterology

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Intake Form
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form 

714 Chase Parkway

Westside Internal Medicine - Suite 6

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Welcome Letter
• Insurance & Registration Form
• New Patient Intake Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form 

1075 Chase Parkway

Joseph Bowen, MD - Suite 6

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form 

1320 West Main Street

Franklin Cardiology

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form 

1389 West Main Street 

Diabetes & Endocrinology Center, Suite 224

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Welcome Letter
• New Patient Intake Form
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form
• Meaningful Use Questionnaire

1981 East Main Street

Waterbury Internal Medicine

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Welcome Letter
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form 

Middlebury

590 Middlebury Road, Suite #A - Shady Macaron, MD

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Intake Form
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form 

Naugatuck

1177 New Haven Road

Naugatuck Internal Medicine

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Welcome Letter
• Insurance & Registration Form
• New Patient Intake Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form 

Prospect

166 Waterbury Road

Prospect Gynecology

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Welcome Letter
• No-Show Waiver Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• New Patient Intake Form
• Insurance & Registration Form
• Meaningful Use Questionnaire

Primary Care Partners, PC

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Welcome Letter
• No-Show Waiver Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• New Patient Intake Form
• Insurance & Registration Form
• Meaningful Use Questionnaire

Pond Place Pediatrics

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• No-Show Waiver Form
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms

The Breast & Oncology Center

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Welcome Letter
• No-Show Policy
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• New Patient Intake Form
• Insurance & Registration Form
• Meaningful Use Questionnaire

Cheshire

1154 Highland Avenue, Cheshire

Cheshire Internal Medicine

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Welcome Letter
• No-Show Policy
• HIPAA Acknowledgment
• New Patient Intake Form
• Insurance & Registration Form
• Meaningful Use Questionnaire

Southbury

33 Bullet Hill Road

The Breast & Oncology Center

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Intake Form 

Robotic and Laparoscopic Surgery Specialists

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form 

385 Main Street South

Southbury Internal Medicine

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Welcome Letter
• New Patient Intake Form
• Insurance & Registration Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form 

Wolcott

503 Wolcott Road

Wolcott Internal Medicine - Dr. Joseph Pruner

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• New Patient Welcome Letter
• Insurance & Registration Form
• New Patient Intake Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form 

Wolcott Internal Medicine - Dr. Peter Giacomazzi

• Authorization of the Release of Information (English)
• Authorization of the Release of Information (Español)
• Insurance & Registration Form
• New Patient Intake Form
• HIPAA Privacy/Treatment/Payment/Healthcare/Operations Forms
• No-Show Waiver Form