Forms

Patient Forms

Notice of Privacy Practices
Buckhead Internal Medicine’s Notice or Privacy Practices describes how your medical information may be used or disclosed. Please review this document carefully. You may obtain a paper copy of this Notice upon request.

New Patient Registration Form
You may fill out this form in advance of your visit to save time at check in. This form is required on your first visit to Buckhead Internal Medicine.

New / Transferring Patient Medical Questionnaire
You may fill out this form in advance of your visit to save time at check in. This form is required on your first visit to Buckhead Internal Medicine.

HIPAA Patient Consent Form & Administrative Policies
Each patient must sign a Patient Consent Form/Administrative Policy. The consent form allows Buckhead Internal Medicine permission to use protected healthcare information about you in order to carry out treatment, payment and general healthcare operations. This form also describes our administrative policies.

Medical Information Release to Buckhead Internal Medicine
Medical Information Release from Buckhead Internal Medicine
To request that medical information about you be sent to another physician, your employer or another entity, these form must be completed and signed. This allows Buckhead Internal Medicine to release or obtain protected medical information on your behalf.

Forms Completion Fees

Our practice receives many requests to complete various patient forms such as insurance, disability, FMLA, and Health Clearance Forms. Completion of these forms requires medical expertise and a review of medical record documentation. For this reason, a fee based on complexity and length of the forms will be collected prior to releasing the form. It is the patient’s responsibility to complete their portion of the form and submit it to the requesting party.

Please refer to the fees indicated for applicable requests. If you mail the form to us, please make sure that you send payment with your request. No forms will be completed prior to payment of fees.

Note that if you have the form completed at the time of an office visit, there is no fee.

Fee: $75

  • Nursing home entrance form
  • Adoption forms
  • Disability forms
  • Assisted living forms
  • FMLA
  • Marta Mobility Form
  • Other Mobility Aid Forms (Scooters, Hoverounds, etc.)

Fee: $30

  • Health Clearance Forms (Gyms, Diet Clinics, etc)

Medical record requests are priced individually. Please call our Medical Records Department to determine your cost.

Please note:

  • Charges are not billable to your insurance provider and are your responsibility
  • All fees must be paid before records are sent
  • Typically no charge for pertinent records sent directly to a specialist
How You Can Help

You can expedite the check-in process by printing these forms, filling them out, and bringing them with you to your first visit.