Established Forms

Patient Information (Complete if last visit over one year ago)

Medicare Insurance Information Questionnaire-If applicable

Buckley and Sudduth Patients Only-Pain Form

We respect patient confidentiality and we are required by the State of Alabama and Federal law to maintain the privacy of your protected health information (PHI). Your health record contains PHI about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required to follow the privacy practices described in this Notice, though we reserve the right to change our privacy practices and the terms of this Notice at any time. The new notice will be effective for all PHI that we maintain at that time. Should our privacy notice change, we will post any revisions.

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