Paperwork


 

Please choose the correct paperwork for your location and the type of appointment you are being seen for.
Completed forms may be brought in at the time of your visit or returned by email to our medical records team at: info@csimp.net



CSIMP New Adult Patient | NFIMP New Adult Patient - These packets are for adult patients (18 years or older) who are new to our office. Please bring these completed forms with you to your appointment as well as a picture ID, insurance cards, and a list of any current medications.

 

CSIMP New Pediatric Patient | NFIMP New Pediatric Patient - These packets are for pediatric patients (17 years or younger) who are new to our office. Please bring these completed forms with you to your appointment as well as a picture ID, insurance cards, and a list of any current medications.

 

CSIMP 12yr Well Child Check | NFIMP 12yr Well Child Check - These packets are for a physical visit with a child who is the age of 12. If this is your first visit of the year, please complete all forms. If you have already completed the yearly paperwork, only complete the form "PHQ-9."

 

CSIMP 13-16yr Well Child Check | NFIMP 13-16yr Well Child Check - These packets are for a physical visit with a child who is ages 13-16. If this is your first visit of the year, please complete all forms. If you have already completed the yearly paperwork, only complete the forms, "PHQ-9" and "Questions for Parents."

 

CSIMP 17yr Well Child Check | NFIMP 17yr Well Child Check - These packets are for a physical visit with a child who is the age of 17. If this is your first visit of the year, please complete all forms. If you have already completed the yearly paperwork, only complete the forms, "PHQ-9" and "Questions for Parents."

 

CSIMP Physical Packet- Female 18-39yr | NFIMP Physical Packet- Female 18-39yr - These packets are for a physical visit with an adult female who is the age of 18-39. If this is your first visit of the year, please complete all forms. If you have already completed the yearly paperwork, only complete the form "Questions for Female Patients."

 

CSIMP Physical Packet- Male 18-39yr | NFIMP Physical Packet- Male 18-39yr - These packets are for a physical visit with an adult male who is the age of 18-39. If this is your first visit of the year, please complete all forms. If you have already completed the yearly paperwork, only complete the form "Questions for Male Patients."

 

CSIMP Physical Packet- Female 40-64yr | NFIMP Physical Packet- Female 40-64yr - These packets are for a physical visit with an adult female who is the age of 40-64. If this is your first visit of the year, please complete all forms. If you have already completed the yearly paperwork, only complete the form "Questions for Female Patients."

 

CSIMP Physical Packet- Male 40-64yr | NFIMP Physical Packet- Male 40-64yr - These packets are for a physical visit with an adult male who is the age of 40-64. If this is your first visit of the year, please complete all forms. If you have already completed the yearly paperwork, only complete the form "Questions for Male Patients."

 

CSIMP Physical Packet- Female 65+ | NFIMP Physical Packet- Female 65+ - These packets are for a physical visit with an adult female who is 65 years of age or older. If this is your first visit of the year, please complete all forms. If you have already completed the yearly paperwork, only complete the forms; "Annual Wellness Health Risk Assessment" (2 pages), "PHQ-9," and "Alcohol Use Assessment."

 

CSIMP Physical Packet- Male 65+ | NFIMP Physical Packet- Male 65+ - These packets are for a physical visit with an adult male who is 65 years of age or older. If this is your first visit of the year, please complete all forms. If you have already completed the yearly paperwork, only complete the forms; "Annual Wellness Health Risk Assessment" (2 pages), "PHQ-9," and "Alcohol Use Assessment."

 

Primary Care Provider Change Request (BCBS) - This form is for existing patients who have transferred insurance to the Blue Cross Blue Shield TennCare plan, also known as BlueCare. Before being seen in office, patients must first change the PCP listed on their insurance card to one of our providers. Please complete this form and return it to the office so our provider can approve. We will send this to the insurance company for this change to be made.

 

Primary Care Provider Change Request (UHC) - This form is for existing patients who have transferred insurance to the United Healthcare TennCare plan, also known as the UHC Community Plan. Before being seen in office, patients must first change the PCP listed on their insurance card to one of our providers. Please complete this form and return it to the office so our provider can approve. We will send this to the insurance company for this change to be made.

 

Release of Information - This form is for patients who wish to have all or a portion of their medical records transferred. It can be used for release of records from our office to another office OR for requesting records from another facility to be sent to our office.

 

Notice of Privacy Practices - This notice describes how health information about you may be used and disclosed. It also describes how you can get access to this information. Please review it carefully, the privacy of your health is important to us.

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