New Patient Packet

Chronic Pain Contract/Forms

Credit Card Authorization Form

Bank Draft Authorization Form

Release of Information Form

Patient Portal Authorization Form

Patient Authorization for Personal Representative

Annual Physical Form -

Non-Medicare:

Please print out and bring the following list of symptoms to your physical exam appointment

Medicare "Annual Wellness Visit" Physical Form:

Please fill out for your Annual Wellness Visit/Annual Physical.  Medicare covers the AWV for beneficiaries who are no longer in the first 12 months of their first Part B coverage period.  This is an annual benefit.

Kentucky Living Will Packet:

End-of-life planning is a required service, upon the beneficiary’s consent, of the Welcome to Medicare Exam.  KY's living will information is available here for download.