Forms


It is the policy of Pinchot Family Medicine to have each new patient complete the following six forms. May we suggest that you printout and complete these forms at home. By filling in the forms in the comfort of your own home you will have ready access to any medication bottles and information you might need to complete the forms:

Welcome to Pinchot Packet
New Patient Packet
Pinchot Plan Enrollment Contract
Notice of Privacy Practices


If you are a parent or guardian, please complete the following form:
Consent for Medical Treatment of Minor

If you are a Medicare recipient, please complete the following form:
Signature Authorization Form Medicare


Protected Health Information (PHI) Release/Authorization Forms


Authorization to release PHI to Pinchot Family Medicine
Take a copy of this filled out form to your current physician, to request that a copy of your medical records be sent to Pinchot Family Medicine. Be aware that your provider may use their own forms, and they may charge fees to make copies of your medical records. Pinchot Family Medicine will take paper copies, but we prefer fax, or any available electronic format.

Authorization for release of PHI
A copy of the same form, but this one is used to request the release of your information from Pinchot Family Medicine, and sent to another requesting party. Pinchot Family Medicine is discouraged by the high fees charged by other practices for copies of patient records, and makes electronic copies of a patient's records available for free. Otherwise our fees follow this schedule:


Fee Schedule:

  1. Request from a District Attorney - $18.54 flat fee
  2. Worker's Compensation - $0.12 per page, plus actual mailing costs.
  3. Request from an Attorney to support a claim or an appeal under the Social Security Act - $23, plus actual mailing costs.
  4. Personal requests for record copying will incur a $0.60/page charge for the first 60 pages and then a $0.30 per page charge for pages 61+, plus mailing costs.