Forms & Policies | Parker At Your Door

Forms

Before receiving care, please complete the appropriate forms to make sure that you understand your rights and responsibilities. We encourage you to read and complete the forms before your visit.

Consent Forms
1 of 2

Consent Forms
2 of 2

Listing of Notices Form

Financial Acknowledgement Form

HIPAA Form

Flu Shot Consent Form

Verbal Disclosure of Protected Health Information

CCM Patient Welcome Letter

Notice of Authorizations & Assignment of Benefits

Telemed Consent

COVID-19 Forms

COVID-19 Immunization Screening and Consent Form

Third Vaccine Form

Pediatric COVID-19 Immunization Screening and Consent Form

Policies

Patient Bill of Rights

Patients’ Responsibilities

Notice of Privacy Practices

Summary of NYC Metro Physician Services PC Financial Policies

Advance Directives

Health Care Proxy

Living Will

Molst Form

Forms

Consent Forms 1 of 2

Consent Forms 2 of 2

Listing of Notices Form

Financial Acknowledgement Form

HIPAA Form

Flu Shot Consent Form

Verbal Disclosure of Protected Health Information

CCM Patient Welcome Letter

Notice of Authorizations & Assignment of Benefits

Telemed Consent

COVID-19 Forms

COVID-19 Immunization Screening and Consent Form

Third Vaccine Form

Pediatric COVID-19 Immunization Screening and Consent Form

Policies

Patient Bill of Rights

Patients’ Responsibilities

Notice of Privacy Practices

Summary of NYC Metro Physician Services PC Financial Policies

Advance Directives

Health Care Proxy

Living Will

Molst Form

NYC – Metro Physician Services PC

Consent Forms
1 of 2

Consent Forms
2 of 2