Patient Forms

NEW PATIENT INTAKE PROCEDURE!

 

Please visit the following website to begin the patient registration process:

https://patients.acomhealth.com/harmonyhealthcare

Once you have completed the form, please notify us so that we can verify your insurance coverage. 

Please arrive at the facility 30 minutes prior to your initial appointment to complete the patient information. We look forward to serving you.



Patient Welcome Packet Contains: 

  • Patient History
  • Patient Missed Appointment Policy
  • Financial Office Policy
  • Financial Responsibility and Assignment of Benefits Policy
  • Patient Acknowledgement of Privacy Practices
  • Patient HIPAA Consent Form


Advance Beneficiary Notice (ABN) - Medicare only  (select option 2)


Athlete Waivers and Forms 

 

  • Athlete Participation and Health History Form.
  • General Liability Waiver


Items to bring to your first visit

  • Identification Card (Driver's License, Student ID, or Passport)
  • Insurance Card
  • Completed Patient  or Athlete Intake Forms.