New Patient Intake Forms

Please download/print and fill out the following patient forms prior to your first visit to Dr. Avart’s offices, if possible.  Doing so will speed up the process when you arrive but if it is inconvenient for you to do so that’s ok.  We can provide you with the patient forms when you arrive.  Thank you!

MyAddictionPhysician medical history and intake form for new patients.

Medical History / Intake Form

Used to capture personal information and details regarding your medical history and habits. All patients must complete this intake form prior to appointment.

Acknowledgement of Privacy Practices form. All patients must receive the privacy practices notification and then sign this form.

Acknowledgement of Receipt of Privacy Practices

This is a document you must sign to acknowledge that you have received the notice of privacy practices from Dr. Avert and MyAddictionPhysician.

This document explains Dr. Avart's financial policies and those of MyAddictionPhysician.

Financial Policies

This form is a summary of financial policies for Dr. Avart and MyAddictionPhysician. Please read it carefully and ask us for assistance if you have questions.

Medical information and HIPAA release form for MyAddictionPhysician.

HIPAA / Medical Information Release Form

Your health information is protected by law. Signing this form gives us your consent to release your health information to parties you authorize.

This document is a notice of privacy practices for Dr. Avart and MyAddictionPhysician.

Notice of Privacy Practices

Please read this document for info about how your health information may be used and shared, and how you can access this information. Your privacy is important to us.