Patient Forms

In an effort to expidite service during your next visit, please choose from the following forms as instructed when you made your appointment. Print the form out and fill in the form as completely as possible. Please bring the completed forms to your next appointment.

• Established Patient Complete Physical Exam Form: This questionnaire assists your Provider in gaining a clear understanding of your current health condition.
• New Patient Form: Medicare : This questionnaire is for new patients with scheduled appointments, to assist your provider in gaining a clear understanding of your current health situation. Please bring completed forms to your scheduled new patient appointment.
• New Patient Form: Commercial Insurance : This questionnaire is for new patients with scheduled appointments, to assist your provider in gaining a clear understanding of your current health situation. Please bring completed forms to your scheduled new patient appointment.
• Preventive Health Consent
• Authorization to Release Information (HIPPA): Authorize CIMA to share your medical record, health status, and results with a person or entity of your choosing. Examples include Family member(s), Healthcare Power of Attorney, etc.
• Release of Medical Records from CIMA: Authorize CIMA to release your medical record to an outside Medical Practice or enitity.
• Request for Medical Records to be sent TO CIMA: Authorize an outside Medical Practice or healthcare entity to share your medical record with CIMA.

Form Completion Fees:

Acknowledgement of Form Fee Completion Policy

Carolina Internal Medicine will charge for completion of various types of forms on your behalf. These include: Disability forms, DMV forms, FMLA forms, and FL2/Nursing Home admission forms. Completion of these forms requires medical expertise and a review of medical record documentation. For this reason, a fee based on complexity and length of the forms will be collected prior to releasing the form.

It is the patient’s responsibility to complete his/her portion of the form and submit it to the requesting party.

This fee will not be filed to your insurance company and will be the patient’s responsibility.

Please refer to the fees indicated for applicable requests. If you mail the form to us, please make sure that you send payment with your request. No forms will be completed prior to payment of fees. Note that if you have the form completed at the time of an office visit, there is no fee.

Below is a list of the fees for forms completed.

• Simple Form Completion $20.00
• Intermediate Form Completion $30.00
• Complex Form Completion $40.00
• FL2 Nursing Home Admission Form Fee $50.00
• FMLA Form $65.00

Returned Check Fee: $30.00

Please note: Form Fee charges are not billable to your insurance provider and are your responsibility.

All fees must be paid before your next appointment with one of our providers

Please call CIMA if you have any questions at (828) 258-0397.