Enrollment Forms

The forms used to enroll you in the clinic are posted here for patient convenience.  Please note that, prior to seeing Dr. Twardon, patients will need to fill out 3 forms, one from each of the following 3 categories:

  • Either Acknowledgement of Medicare Opt-Out or Acknowledgement of Insurance Opt-Out
  • Acknowledgement of HIPAA Notification of Privacy Practices (after reviewing the Notice, also included below)
  • A Contract (either Membership or Fee-For-Service)

       To download the appropriate printable PDF for each, select the corresponding line below whereever it says "Click Here."

Acknowledgement of Medicare/Insurance Opt-Out

Medicare Requires that this form be signed (Click Here to pull up a printable PDF of the Medicare Form).

Click Here for the corresponding form for non-Medicare patients.

HIPAA Notice and your Acknowledgement

The Federal Government Requires that my office notify you of this Federally mandated privacy standard (Click Here--this Notice is also posted at the clinic in full);

and further Requires this acknowledgement form be signed as well (Click Here)!

Contract

For most patients with more than a few simple problems to deal with in a year, we encourage annual "Membership."  This is described in more detail under the webpage for "Pricing" (Click Here for the contract available as a PDF file).

For patients who truly anticipate only needing to address 1 or 2 simple problems, once or twice a year, or especially patients who don't expect to be following up long term (ie, visiting from out of town), the more limited "Fee For Service" plan may be more appropriate (click Here for this PDF printable file).  For persons who have, or may expect to have, need for more time with Dr. Twardon, we encourage considering "Membership" model, above.