Patient Forms

Internal Medicine

Physical Therapy

Adult New Patient

New adult patients, please complete this form and bring it with you to your appointment.

Internal Medicine Questionnaire

New internal medicine patients,  please complete this form prior to your appointment.

OB/GYN

Adult New Patient

New adult patients, please complete this form and bring it with you to your appointment.

OB/GYN

Health History 

Please complete this form and bring it to your OB/GYN appointment. 

Physical Therapy New Patient 

New Physical Therapy patients, please complete the intake form below and bring it with you to your appointment.

Physical Therapy New Patient- MALE PELVIC

​If you are a male pelvic physical therapy patient, please instead fill out the appropriate form below.

Physical Therapy New Patient- FEMALE PELVIC

​If you are a female pelvic or women’s health physical therapy patient, please instead fill out the appropriate form below.

Pediatrics

General

Pediatric New Patient

New pediatric patients/parents, please complete these forms and bring them with you to your appointment.

MCHAT Well Check Form-18, 24 and 30 Months 

This form will help our pediatricians to better prepare for your visit.

NICHQ Assessment Scale: PARENT

​Fill out this assessment as directed by your child's pediatrician.

NICHQ Assessment Scale: TEACHER

Fill out this assessment as directed by your student's pediatrician/parent or guardian.

WIAA PPE

​Patients 18+ or parents with children 18 years or younger who need a preparticipation physical evaluation (PPE): please fill out the first two pages of this form BEFORE the appointment. 

Ages and Stages Questionnaire

​This questionnaire will help your physician and nurses to better understand how your child is developing and identify any potential concerns.

NICHQ Assessment Follow-Up: PARENT

​Fill out this assessment follow-up as directed by your child's pediatrician.

NICHQ Assessment Follow-Up: TEACHER

​Fill out this assessment follow-up as directed by your student's pediatrician/parent or guardian.

Workers Compensation

​If your visit pertains to an injury sustained at work,  please come ready with the claim information.  The linked forms below will help you to gather this information so we can correctly bill for your visit.

MyChart Proxy

By clicking below, users can request online access to medical information for their children or another in their care that has impaired decision-making abilities. Adult patients may also authorize spouses, adult children, or others to have access to their existing  account.​

Disclosure Authorization Form

​Use this form to authorize Associated Physicians to discuss or disclose your protected health information to the people that you specify.

Medicare Educational Resources

To monitor Medicare, the government has several processes and forms in place that may be new to you. We are required to strictly adhere to these Medicare requirements. 

Third Party Liability

​Third party liability occurs when someone else (an individual, organization, or business) may have been responsible for your injury or illness.  When this is the case, that entity or its insurer may be liable to pay your health insurance claims related to that injury or illness.

Transfer of Medical Records/Authorization for Release of Records

To request copies of or to transfer your medical records, you must submit a request in writing using this form. Your records will then be sent to the requested entity through a secure portal. Requests can take 1-2 weeks to process depending on the information requested.

Advanced Directives

If you or your loved one needs help making decisions about healthcare, you can find Power of Attorney and Living Will forms by clicking below. Please present these forms when you arrive for your visit.

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© 2023 by Associated Physicians, LLP

4410 Regent St. Madison, WI 53705

608-233-9746

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