Patient Forms

To make your initial consultation process the simplest as possible, we recommend printing the following forms and completing them prior to arriving at our office. This will help us avoid delays because we recognize that your time is important as well. We look forward to meeting you or seeing you again!

Medical History Form

HIPAA Form (read-only – do not print)

Patient Financial policy (read-only – do not print)

Forms below are not needed for new patient appointments unless they apply to you.

Notice of Privacy Practices

Consent to Treat Minor Children

Consent to Treat Minor Without Parent

Hair Loss Insurance Coverge

If you need your medical records released for any reason or would like to have your records sent to our office, please review the guidelines below:

•    If you would like to receive paper copies of your records, there will be a fee based on the current year’s fee schedule allowed by the Pennsylvania Judicial Code depending on the number of pages that are copied. The current fee schedule can be seen here. At this time, we are unable to provide electronic copies of medical records.
•    Fees for any of the above requests will be due before the medical records are released.
•    If you are transitioning to our office from another provider, you can request your medical records be sent to us directly from their office, or you can use the form linked below. If using our form, please select “Receive Medical Records From” and put the previous physician’s information on the provided lines. Please also include their fax number somewhere on the form so we are able to send over the release.
•    Please allow up to 30 days for records requests to be processed.
•    When your medical records are ready, our office will notify you. If you wish to have your medical records mailed, you are responsible for the postage, shipping, and delivery charges. We are able to fax your records without and an additional fee to private and secure fax.
•    Requests for medical records by specialists to whom we have referred your care will be provided in summary for free of charge.
•    You will need to fill out a separate request form for each party you wish to have your records sent from/to.
•    Additional fees will apply for records requested by attorneys and insurance companies because of the nature of their requests. Those fees are traditionally paid by the requesting party. The request must come directly from that party on their request form.
•    We are not permitted by law to release any documents which have not been created by our practice. If you are looking to obtain another provider’s medical records that have been sent to our office, including letters of recommendation, you will need to request them from the provider of origin.

Medical Records Release Form

The form may be returned to our office by fax at 610-820-9983, via mail, or via email to info@asasurgery.com

REFUND POLICY FOR ONLINE PAYMENTS:
If a charge is made in error, please contact our office for a refund at 610-437-2378