Registration Forms

To facilitate a timely office visit, please download, print, and complete the forms listed below. The forms listed below are in .pdf file format. If you do not have a .pdf reader, a free download is available here.

• Patient Registration Form: Personal and insurance information, medical records release so we can bill your insurance, and permission to obtain medication history.  
• Designation of Personal Representative: The person you list as a personal representative will be the only person we can speak with regarding your medical condition and records. You may designate more than one person. If you do not want a designated representative, please only sign the last signature and date lines.  
• Narcotic Agreement: We are required by the State of Kentucky to obtain a narcotic medication report (KASPER) on our patients. As a courtesy, we are having you sign this form to show that you are aware of this. As a rule, very little narcotic medication is dispensed from this office. Patients in need of pain medication are referred to Pain Management. 
• HIPAA: Explains your Privacy Rights. This is for you to read and keep.  
• Message Authorization Form 

• Complete Patient Registration Form, Designation of Personal Representative, Narcotic Agreement, and Message Authorization Forms. 
• Updated insurance card. 
• Identification cards such as a driver’s license. 
• An updated list of medications. You may bring your medication containers and bottles. 
• An updated list of surgeries. 
• An updated list of other practitioners and specialists involved in your care. 

Hours of Operation

• Monday, Tuesday, and Thursday, 8 a.m.-12 p.m. | 1 p.m.-4 p.m. (Closed for Lunch) 
  
• Wednesday, 8 a.m.-12 p.m. 
  
• Closed Most Fridays