Patient Forms | Associated Physicians | Madison, WI

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Nurse Form

PATIENT
FORMS

GENERAL

General

Please review the forms below to download a PDF that you may send electronically to our Patient Access Department, or in-person at our clinic. All medication refills have an expected lead time of 5 - 7 days.

MyUnityPoint Proxy

By clicking below, users can request online access to medical information for their children or another in their care that has impaired decision-making abilities. Adult patients may also authorize spouses, adult children, or others to have access to their existing account.

Disclosure Authorization Form

Use this form to authorize Associated Physicians to discuss or disclose your protected health information to the people that you specify.

Medicare Educational Resources

To monitor Medicare, the government has several processes and forms in place that may be new to you. We are required to strictly adhere to these Medicare requirements.

Release of Information

Please complete this form to release PHI or protected health information.

Transfer of Medical Records/Authorization for Release of Records

To request copies of or to transfer your medical records, you must submit a request in writing using this form. Your records will then be sent to the requested entity through a secure portal. Requests can take 1-2 weeks to process, depending on the information requested.

Advance Directives

If you or your loved one needs help making decisions about healthcare, you can find Power of Attorney and Living Will forms by clicking below. Please present these forms when you arrive for your visit.

Worker’s Comp and Third Party Liability

Please complete this form if you have been injured in an accident at work or when another party is responsible

Internal Medicine

Adult New Patient

New adult patients, please complete this form and bring it with you to your appointment.

Internal Medicine Questionnaire

New internal medicine patients, please complete this form prior to your appointment.

Internal Medicine

OB/GYN

Adult New Patient

New adult patients, please complete this form and bring it with you to your appointment.

OB/GYN Health History

Please complete this form and bring it to your OB/GYN appointment.

OB/GYN

Pediatrics

Pediatric New Patient

Please complete this form and bring it with you to your pediatric new patient appointment.

MCHAT Well Check Form-18, 24 and 30 Months

This form will help our pediatricians to better prepare for your visit.

NICHQ Assessment Follow-Up: PARENT

Fill out this assessment follow-up as directed by your child's pediatrician.

NICHQ Assessment Follow-Up: TEACHER

Fill out this assessment follow-up as directed by your student's pediatrician/parent or guardian.

WIAA PPE

Patients 18+ or parents with children 18 years or younger who need a preparticipation physical evaluation (PPE): please fill out the first two pages of this form BEFORE the appointment.

NICHQ Assessment Scale: PARENT

Fill out this assessment as directed by your child's pediatrician.

NICHQ Assessment Scale: TEACHER

Fill out this assessment as directed by your student's pediatrician/parent or guardian.

Pediatrics

Behavioral Health

Behavioral Health Consent to Treat

New Behavioral Health patients, please complete this form and have it ready for your first appointment.

Behavioral Health Telehealth Consent

Behavioral Health patients being seen virtually, please complete this form and have it ready in advance of your appointment.

Behavioral Health

Physical Therapy

Physical Therapy

Physical Therapy New Patient

New Physical Therapy patients, please complete the intake form below and bring it with you to your appointment.

Physical Therapy New Patient- MALE PELVIC

If you are a male pelvic physical therapy patient, please instead fill out the appropriate form below.

Physical Therapy New Patient- FEMALE PELVIC

If you are a female pelvic or women’s health physical therapy patient, please instead fill out the appropriate form below.

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