Doctor Appointment Forms

Forms for Health Care Clinics
Please download and review the forms below PRIOR to your first appointment.  The completed registration and applicable agreement forms are required at your first session. The email and SMS text policy is applicable only if you are requesting to use either mode of communication in sharing health information directly with your doctors. Call or stop by with questions!
Medicare Patients
Dr. Tansey and Dr. Cartaya have opt-out status with Medicare.
In addition to the registration and agreement forms above, federal law requires their Medicare-enrolled patients to complete and sign a private contract before any health care is initiated.
MEDICARE AGREEMENT FORM
 
Obtaining Medical Information
If you are requesting other care providers send your health information for our doctors to review prior to your appointment or during your clinical care, click on the left link for the consent form authorizing release, and mail the completed and signed form to your provider. If you are working with providers at the University of Iowa (UIHC), please click the right link to be connected to their specific directions.
Consent to Obtain Information                           Obtain UIHC Medical Records
Releasing Medical Information
If you are requesting that our doctors provide a summary or copy of your health records from our office, please click on the link below and complete the form for every person/office whom you would like to receive your health information.  Bring the signed forms to your next appointment, or mail them to our office, specifying all details that will help us accurately fulfill your request.