Forms

Patient Forms

Please select the appropriate packet to print and complete. You are not required to complete any other forms on this page, as these packets contain all necessary forms for new patients. 

Patient Packet, Non-pregnant

Patient Packet, Pregnant


Medical Release Forms

NEW PATIENTS TO TEPEYAC: Use this form to have your medical records sent TO TEPEYAC from another practice: Records Release TO Tepeyac OB/GYN Form

CURRENT TEPEYAC PATIENTS: Use this form if you need medical records released FROM Tepeyac OB/GYN to another practice. Please note that it takes several days for records release requests to be processed. There may be a charge for this service. Records Release FROM Tepeyac OB/GYN Form

 

Other Forms and Services

Disability Forms:  If you are filing a disability claim, please send your forms to the office. Requests for disability forms have the following charges:

               Charge for completing forms is $25.00 ($5.00 for each additional page after the initial page).

               An additional $20.00 fee will be assessed for requests without a 24-hour notice.

A document replacement fee for lost prescriptions, forms, or letters will be assessed at $30.00 per item.

 

HIPAA

All new patients need to read the Privacy Notice, sign the Receipt, and return the receipt to the front desk at their initial visit. Established patients should review the Privacy Notice and sign an updated receipt annually or when the Notice is updated. You may sign the Privacy Notice electronically at Tepeyac’s Patient Portal at https://myhealthrecord.com/Portal/SSO if you register for our secure messaging site. Please read The Privacy Notice, which was last updated in August 2014.

You may also be interested in optional forms mentioned in the Privacy Notice that you can obtain by clicking on the links below:

Fundraising Options Form:  Divine Mercy Care may use limited patient information to contact you for fundraising purposes. You may opt out of fundraising or opt back in using this form.

List of Disclosures Request Form:  You may request a list of disclosures made of your information which were not for purpose of your treatment, payment, or Tepeyac operations, and not otherwise made at your request. Please use this form to ask us to account for such disclosures.