KYMERA'S PATIENT FORMS REQUIRED FOR THE FIRST APPOINTMENT / VISIT

DOWNLOAD THE FORMS HERE (pdf 7mb)

To save you time on the day of your appointment:
Print; fill out at home; bring to your first appointment -- 10 minutes prior.
If not filled out at home please show up at your appointment -- 30 minutes prior.

PATIENT & INSURANCE INFORMATION - FORM ( 2 pages)
Patient Information
Guarantor Information (if patient is under 18)
Primary Insurance Information
Secondary Insurance Information
MEDICAL HISTORY - FORM (1 page)

*MEDICARE PATIENT - FORM (2 pages) (*Medicare patients only)

PATIENT CONSENT TO THE USE & DISCLOSURE OF INDIVIDUALLY

IDENTIFIABLE HEALTH INFORMATION FOR TREATMENT,

PAYMENT, AND / OR HEALTH CARE OPERATIONS - FORM (1 page)

NOTICE OF PRIVACY PRACTICES (2 pages) (Please read -- nothing to sign)

DOWNLOAD THE FORMS HERE (pdf 7mb)