Below are some key documents that will allow us to better serve you and improve the expedience of your enrollment as a new member in Trout Lake Clinic.
TLC Patient Agreement
The official care contract. Please print this off, fill it out and bring it with your initial payment to the clinic. Dr. Harpe will sign his portion of the contract at the clinic, and provide a copy to you for your records.
Agreement Addendum 1
Reviews the policy/practices of the care agreement, for patient review and awareness.
Agreement Addendum 2 (Medicare opt out)
For review and signature by all patients on Medicare, indicating Dr. Harpe opted out of Medicare and patient cannot file for reimbursement from Medicare.
This form reviews the payments options and considerations of each. You can also utilize this form as an existing patient to update your payment information.
Patient Information Sheet
This form provides current contact information for our records. Please print and fill out this form and bring it to your first appointment. Also utilize this form if your contact information has changed.
This form provides Dr. Harpe with your past medical history and prior care, in order to help smooth your transition to the practice and ensure a complete understanding of your medical history.
Notice of Privacy Practices
A list of your rights under HIPPA. This information is for your awareness and review. It does not have to be printed out and signed. Please read and understand prior to your first appointment.
Receipt and Acknowledgement of Privacy Practices
Your acknowledgement that we have provided you with awareness of your rights under HIPPA. After reviewing the Notice of Privacy Practices, please print out this form, sign it and bring it to your first care appointment.
Please let us know if you have any questions. We look forward to seeing you soon.