Forms and Questionnaires Download Area
Welcome to the Victory Physicians online Forms page. On this webpage you will find forms to speed up your visit and coordinate your care. Many of these forms are live and you may type your answers directly onto the form, save and print it. To save and print you will need to download the PDF applications at the bottom of this page and follow the instructions closely. It is very important that you fill out all appropriate forms before you arrive or time spent filling out forms will be deducted from your appointment slot time and you will have less face to face time with the doctor.
REGISTRATION
NEW INSURED PATIENTS
(INCLUDES OLD PRACTICE PATIENTS NOT REESTABLISHED)
- Form A1: Registration Form
- Form B1: Commercial Insurance Form-Check Acceptance Policy
- Form C: Billing Policy
- Form D: Understanding Your Financial Obligations
- Form E: (5 pages): Notice of Privacy Practices
- Form F: Clinical Pathway Declaration
- Form G: Review of Systems
NEW MEDICARE AND MEDICARE REPLACEMENT INSURED PATIENTS
(INCLUDES OLD PRACTICE PATIENTS NOT REESTABLISHED)
- Form A1: Registration Form
- Form B2: Medicare Form
- Form B3: Check Acceptance Policy
- Form C: Billing Policy
- Form D: Understanding Your Financial Obligations
- Form E: (5 pages): Notice of Privacy Practices
- Form F: Clinical Pathway Declaration
- Form G: Review of Systems
NEW UNINSURED SELF-PAY PATIENTS
(INCLUDES OLD PRACTICE PATIENTS NOT REESTABLISHED)
- Form A2: Registration Form
- Form B3: Check Acceptance Policy
- Form C: Billing Policy
- Form D: Understanding Your Financial Obligations
- Form E: (5 pages): Notice of Privacy Practices
- Form F: Clinical Pathway Declaration
- Form G: Review of Systems
ALL RETURNING REESTABLISHED PATIENTS
PREVENTIVE MEDICINE SCREENING
- Complete Preventive Screening
- Cancer Family History
- Preventive Care Review of Systems
- Vaccination History
- Safety Sheet
CONTROLLED SUBSTANCES
PAIN PILLS
- Pain Management Contract
- Pain Log
- Initial Pain Management Questionnaire (ALL NEW PATIENTS ONLY)
- Periodic Pain Management Questionnaire (January, April, July, October ALL RETURNING PATIENTS)
- Interval Pain Management Questionnaire ( All other months except Jan, Apr, Jul, Oct ALL RETURNING PATIENTS)
- Narcotic Information Sheet (ALL PATIENTS)
- Narcotic Therapy Rules and Regulations (ALL PATIENTS)
- Pain Management Checkout Questionnaire (ALL PATIENTS)
SLEEPING PILLS
ANXIETY PILLS
TREATMENT
- Refusal To Permit All Screening
- Refusal To Permit Screening
- Blood Pressure Log
- Blood Sugar Log
- Calorie Log
- Weight Log
- Temperature Log
- Ins & Outs Log
- Diarrhea Log
- Symptom Log
- CAPA Free Diet
- Ulcer & Gastritis Diet/Precautions
DEPARTMENT OF MOTOR VEHICLES (DMV)
- Department of Transportation Physical Exam (DOT)
- Application for Disabled Person Parking Placard or Plates
- Driver Medical Evaluation
DISABILITY
END OF LIFE
- POLST (Physicians Order For Life Sustaining Treatment)
- Advanced Directives & Durable Power of Attorney For Medical Care by State
- Five Wishes
MISCELLANEOUS FORMS
- Release Of Authorization For Medical Records (To Get Us Records)
- Authorization to Disclose Healthcare Information
Print a PDF (Adobe Reader) file
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Save a PDF (Adobe Reader) file
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