{"id":821,"date":"2025-06-13T14:38:47","date_gmt":"2025-06-13T14:38:47","guid":{"rendered":"https:\/\/ridgemediallc.dev\/renew\/?page_id=821"},"modified":"2025-06-13T15:06:32","modified_gmt":"2025-06-13T15:06:32","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/ridgemediallc.dev\/renew\/patient-forms\/","title":{"rendered":"Patient Forms"},"content":{"rendered":"

[et_pb_section fb_built=”1″ _builder_version=”4.27.4″ _module_preset=”default” background_position=”top_center” min_height=”500px” height=”50vh” hover_enabled=”0″ custom_css_main_element=”display: flex;||flex-direction: column;” global_colors_info=”{}” background_enable_image=”off” background_color=”#3f7fc2″ sticky_enabled=”0″][et_pb_row _builder_version=”4.27.4″ _module_preset=”default” width=”90%” hover_enabled=”0″ global_colors_info=”{}” sticky_enabled=”0″][et_pb_column type=”4_4″ _builder_version=”4.24.0″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.27.4″ _module_preset=”default” text_font=”|300|||||||” text_text_color=”#FFFFFF” text_font_size=”24px” text_line_height=”1.2em” header_font=”|700|||||||” header_text_color=”#FFFFFF” header_font_size=”63px” header_2_text_color=”#FFFFFF” header_2_font_size=”64px” text_orientation=”center” width_last_edited=”off|phone” hover_enabled=”0″ text_font_size_tablet=”24px” text_font_size_phone=”18px” text_font_size_last_edited=”on|phone” header_font_size_tablet=”” header_font_size_phone=”10vw” header_font_size_last_edited=”on|phone” header_2_font_size_tablet=”64px” header_2_font_size_phone=”10vw” header_2_font_size_last_edited=”on|phone” global_colors_info=”{}” sticky_enabled=”0″]<\/p>\n

Patient Forms<\/h1>\n

[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=”1″ _builder_version=”4.27.4″ _module_preset=”default” background_image=”https:\/\/ridgemediallc.dev\/renew\/wp-content\/uploads\/2024\/02\/logo-icon-green.png” background_size=”custom” background_image_height=”105%” background_position=”bottom_left” background_horizontal_offset=”-5%” custom_padding=”||||false|false” hover_enabled=”0″ global_colors_info=”{}” sticky_enabled=”0″][et_pb_row _builder_version=”4.27.4″ _module_preset=”default” column_structure=”1_2,1_2″ hover_enabled=”0″ sticky_enabled=”0″ width=”90%” make_equal=”on” custom_padding=”||||false|false”][et_pb_column _builder_version=”4.27.4″ _module_preset=”default” type=”1_2″][dnxte_blurb _builder_version=”4.27.4″ _module_preset=”default” blurb_heading=”Notice of Privacy Practices” hover_enabled=”0″ sticky_enabled=”0″ blurb_description=”<\/p>\n

How health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.<\/p>\n

” dnxt_btn_show_hide=”on” button_link_new_window=”on” button_link=”https:\/\/www.myprivia.com\/sites\/default\/files\/2023-07\/Notice_of_Privacy_Practices_8042.pdf” button_text=”View Form” custom_button=”on” button_text_color=”#8dc63f” button_text_color__hover=”#FFFFFF” button_text_color__hover_enabled=”on|hover” button_bg_color=”RGBA(255,255,255,0)” button_bg_color__hover=”#8dc63f” button_bg_color__hover_enabled=”on|desktop” button_border_color=”#8dc63f” button_border_radius=”5px” button_use_icon=”off” btn_show_hide=”off” border_radii_dnxt_button_borders=”on|5px|5px|5px|5px” border_color_all_dnxt_button_borders=”#8dc63f” dnxt_button_padding=”0.25em|2em|0.25em|2em|true|true” dnxt_btn_text_text_color=”#8dc63f” dnxt_btn_text_font_size=”20px” dnxt_btn_text_font=”||||||||” dnxt_heading_text_color=”#3f7fc2″ dnxt_heading_text_align=”center” dnxt_heading_font_size=”32px” dnxt_heading_font=”|600|||||||” dnxt_body_text_align=”center” dnxt_body_line_height=”2em” dnxt_body_font=”–et_global_body_font||||||||” dnxt_body_text_color=”#b4aeae” dnxt_body_font_size=”18px” dnxt_btn_text_text_align=”center” background_color=”#FFFFFF” box_shadow_style=”preset3″ box_shadow_vertical=”0px” box_shadow_blur=”68px” border_radii=”on|10px|10px|10px|10px” custom_padding=”64px|64px|64px|64px|true|true” custom_padding_tablet=”128px|96px|128px|96px|true|true” custom_padding_phone=”|32px|64px|32px|false|true” custom_padding_last_edited=”on|phone” dnxt_header_margin=”||16px||false|false” dnxt_body_margin=”||||false|false” dnxt_content_margin=”||16px||false|false” custom_css_main_element=”display: flex;||flex-direction: column;” custom_css_free_form=”selector, selector .et_pb_module_inner {|| height: 100%;||}||||selector .dnxt-blurb-wrapper-outer {||\theight: 100%;|| display: flex !important;|| align-items: center;||}” dnxt_hover_bg=”dnxt-hover-fade” dnxt_hover_bg_color=”#8dc63f” dnxt_btn_text_text_color__hover_enabled=”off|hover” dnxt_btn_text_text_color__hover=”#FFFFFF” dnxt_hover_border_bg_color=”#FFFFFF” custom_css_button_wrapper__hover_enabled=”on|hover” custom_css_button_wrapper__hover=”color: #fff !important;”][\/dnxte_blurb][\/et_pb_column][et_pb_column _builder_version=”4.27.4″ _module_preset=”default” type=”1_2″][dnxte_blurb _builder_version=”4.27.4″ _module_preset=”default” blurb_heading=”Authorization for Release of Medical Information” hover_enabled=”0″ sticky_enabled=”0″ blurb_description=”<\/p>\n

Authorize the disclosure of your health information to a designated individual, company, agency, or facility<\/p>\n

” dnxt_btn_show_hide=”on” button_link_new_window=”on” button_link=”https:\/\/www.myprivia.com\/sites\/default\/files\/2023-07\/Authorization_Release_Form.pdf” button_text=”View Form” custom_button=”on” button_text_color=”#8dc63f” button_text_color__hover=”#FFFFFF” button_text_color__hover_enabled=”on|hover” button_bg_color=”RGBA(255,255,255,0)” button_bg_color__hover=”#8dc63f” button_bg_color__hover_enabled=”on|desktop” button_border_color=”#8dc63f” button_border_radius=”5px” button_use_icon=”off” btn_show_hide=”off” border_radii_dnxt_button_borders=”on|5px|5px|5px|5px” border_color_all_dnxt_button_borders=”#8dc63f” dnxt_button_padding=”0.25em|2em|0.25em|2em|true|true” dnxt_btn_text_text_color=”#8dc63f” dnxt_btn_text_font_size=”20px” dnxt_btn_text_font=”||||||||” dnxt_heading_text_color=”#3f7fc2″ dnxt_heading_text_align=”center” dnxt_heading_font_size=”32px” dnxt_heading_font=”|600|||||||” dnxt_body_text_align=”center” dnxt_body_line_height=”2em” dnxt_body_font=”–et_global_body_font||||||||” dnxt_body_text_color=”#b4aeae” dnxt_body_font_size=”18px” dnxt_btn_text_text_align=”center” background_color=”#FFFFFF” box_shadow_style=”preset3″ box_shadow_vertical=”0px” box_shadow_blur=”68px” border_radii=”on|10px|10px|10px|10px” custom_padding=”64px|64px|64px|64px|true|true” custom_padding_tablet=”128px|96px|128px|96px|true|true” custom_padding_phone=”|32px|64px|32px|false|true” custom_padding_last_edited=”on|phone” dnxt_header_margin=”||16px||false|false” dnxt_body_margin=”||||false|false” dnxt_content_margin=”||16px||false|false” custom_css_main_element=”display: flex;||flex-direction: column;” custom_css_free_form=”selector, selector .et_pb_module_inner {|| height: 100%;||}||||selector .dnxt-blurb-wrapper-outer {||\theight: 100%;|| display: flex !important;|| align-items: center;||}” custom_css_button_wrapper__hover_enabled=”on|hover” custom_css_button_wrapper__hover=”color: #fff !important;”][\/dnxte_blurb][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.27.4″ _module_preset=”default” column_structure=”1_2,1_2″ hover_enabled=”0″ sticky_enabled=”0″ width=”90%” make_equal=”on”][et_pb_column _builder_version=”4.27.4″ _module_preset=”default” type=”1_2″][dnxte_blurb _builder_version=”4.27.4″ _module_preset=”default” blurb_heading=”Authorization and Consent for Treatment” hover_enabled=”0″ sticky_enabled=”0″ blurb_description=”<\/p>\n

All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.<\/p>\n

” dnxt_btn_show_hide=”on” button_link_new_window=”on” button_link=”https:\/\/www.myprivia.com\/sites\/default\/files\/2023-07\/Authorization_and_Consent_for_Treatment_Form.pdf” button_text=”View Form” custom_button=”on” button_text_color=”#8dc63f” button_text_color__hover=”#FFFFFF” button_text_color__hover_enabled=”on|hover” button_bg_color=”RGBA(255,255,255,0)” button_bg_color__hover=”#8dc63f” button_bg_color__hover_enabled=”on|desktop” button_border_color=”#8dc63f” button_border_radius=”5px” button_use_icon=”off” btn_show_hide=”off” border_radii_dnxt_button_borders=”on|5px|5px|5px|5px” border_color_all_dnxt_button_borders=”#8dc63f” dnxt_button_padding=”0.25em|2em|0.25em|2em|true|true” dnxt_btn_text_text_color=”#8dc63f” dnxt_btn_text_font_size=”20px” dnxt_btn_text_font=”||||||||” dnxt_heading_text_color=”#3f7fc2″ dnxt_heading_text_align=”center” dnxt_heading_font_size=”32px” dnxt_heading_font=”|600|||||||” dnxt_body_text_align=”center” dnxt_body_line_height=”2em” dnxt_body_font=”–et_global_body_font||||||||” dnxt_body_text_color=”#b4aeae” dnxt_body_font_size=”18px” dnxt_btn_text_text_align=”center” background_color=”#FFFFFF” box_shadow_style=”preset3″ box_shadow_vertical=”0px” box_shadow_blur=”68px” border_radii=”on|10px|10px|10px|10px” custom_padding=”64px|64px|64px|64px|true|true” custom_padding_tablet=”128px|96px|128px|96px|true|true” custom_padding_phone=”|32px|64px|32px|false|true” custom_padding_last_edited=”on|phone” dnxt_header_margin=”||16px||false|false” dnxt_body_margin=”||||false|false” dnxt_content_margin=”||16px||false|false” custom_css_main_element=”display: flex;||flex-direction: column;” custom_css_free_form=”selector, selector .et_pb_module_inner {|| height: 100%;||}||||selector .dnxt-blurb-wrapper-outer {||\theight: 100%;|| display: flex !important;|| align-items: center;||}” dnxt_hover_bg=”dnxt-hover-fade” dnxt_hover_bg_color=”#8dc63f” dnxt_btn_text_text_color__hover_enabled=”off|hover” dnxt_btn_text_text_color__hover=”#FFFFFF” dnxt_hover_border_bg_color=”#FFFFFF” custom_css_button_wrapper__hover_enabled=”on|hover” custom_css_button_wrapper__hover=”color: #fff !important;”][\/dnxte_blurb][\/et_pb_column][et_pb_column _builder_version=”4.27.4″ _module_preset=”default” type=”1_2″][dnxte_blurb _builder_version=”4.27.4″ _module_preset=”default” blurb_heading=”Preferred Contacts” hover_enabled=”0″ sticky_enabled=”0″ blurb_description=”<\/p>\n

Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos<\/a><\/p>\n

” dnxt_btn_show_hide=”on” button_link_new_window=”on” button_link=”https:\/\/www.myprivia.com\/sites\/default\/files\/2023-07\/Preferred_Contacts.pdf” button_text=”View Form” custom_button=”on” button_text_color=”#8dc63f” button_text_color__hover=”#FFFFFF” button_text_color__hover_enabled=”on|hover” button_bg_color=”RGBA(255,255,255,0)” button_bg_color__hover=”#8dc63f” button_bg_color__hover_enabled=”on|desktop” button_border_color=”#8dc63f” button_border_radius=”5px” button_use_icon=”off” btn_show_hide=”off” border_radii_dnxt_button_borders=”on|5px|5px|5px|5px” border_color_all_dnxt_button_borders=”#8dc63f” dnxt_button_padding=”0.25em|2em|0.25em|2em|true|true” dnxt_btn_text_text_color=”#8dc63f” dnxt_btn_text_font_size=”20px” dnxt_btn_text_font=”||||||||” dnxt_heading_text_color=”#3f7fc2″ dnxt_heading_text_align=”center” dnxt_heading_font_size=”32px” dnxt_heading_font=”|600|||||||” dnxt_body_text_align=”center” dnxt_body_line_height=”2em” dnxt_body_font=”–et_global_body_font||||||||” dnxt_body_text_color=”#b4aeae” dnxt_body_font_size=”18px” dnxt_btn_text_text_align=”center” background_color=”#FFFFFF” box_shadow_style=”preset3″ box_shadow_vertical=”0px” box_shadow_blur=”68px” border_radii=”on|10px|10px|10px|10px” custom_padding=”64px|64px|64px|64px|true|true” custom_padding_tablet=”128px|96px|128px|96px|true|true” custom_padding_phone=”|32px|64px|32px|false|true” custom_padding_last_edited=”on|phone” dnxt_header_margin=”||16px||false|false” dnxt_body_margin=”||||false|false” dnxt_content_margin=”||16px||false|false” custom_css_main_element=”display: flex;||flex-direction: column;” custom_css_free_form=”selector, selector .et_pb_module_inner {|| height: 100%;||}||||selector .dnxt-blurb-wrapper-outer {||\theight: 100%;|| display: flex !important;|| align-items: center;||}” dnxt_body_link_text_color=”#8dc63f” dnxt_body_link_font=”||||on||||” custom_css_button_wrapper__hover_enabled=”on|hover” custom_css_button_wrapper__hover=”color: #fff !important;”][\/dnxte_blurb][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.27.4″ _module_preset=”default” column_structure=”1_2,1_2″ hover_enabled=”0″ sticky_enabled=”0″ width=”90%” make_equal=”on”][et_pb_column _builder_version=”4.27.4″ _module_preset=”default” type=”1_2″][dnxte_blurb _builder_version=”4.27.4″ _module_preset=”default” blurb_heading=”Financial Policy” hover_enabled=”0″ sticky_enabled=”0″ blurb_description=”<\/p>\n

This form advises patients of their financial responsibility for all medical services received without regard to insurance eligibility or coverage
determinations.<\/p>\n

” dnxt_btn_show_hide=”on” button_link_new_window=”on” button_link=”https:\/\/www.myprivia.com\/sites\/default\/files\/2023-07\/Financial_Policy.pdf” button_text=”View Form” custom_button=”on” button_text_color=”#8dc63f” button_text_color__hover=”#FFFFFF” button_text_color__hover_enabled=”on|hover” button_bg_color=”RGBA(255,255,255,0)” button_bg_color__hover=”#8dc63f” button_bg_color__hover_enabled=”on|desktop” button_border_color=”#8dc63f” button_border_radius=”5px” button_use_icon=”off” btn_show_hide=”off” border_radii_dnxt_button_borders=”on|5px|5px|5px|5px” border_color_all_dnxt_button_borders=”#8dc63f” dnxt_button_padding=”0.25em|2em|0.25em|2em|true|true” dnxt_btn_text_text_color=”#8dc63f” dnxt_btn_text_font_size=”20px” dnxt_btn_text_font=”||||||||” dnxt_heading_text_color=”#3f7fc2″ dnxt_heading_text_align=”center” dnxt_heading_font_size=”32px” dnxt_heading_font=”|600|||||||” dnxt_body_text_align=”center” dnxt_body_line_height=”2em” dnxt_body_font=”–et_global_body_font||||||||” dnxt_body_text_color=”#b4aeae” dnxt_body_font_size=”18px” dnxt_btn_text_text_align=”center” background_color=”#FFFFFF” box_shadow_style=”preset3″ box_shadow_vertical=”0px” box_shadow_blur=”68px” border_radii=”on|10px|10px|10px|10px” custom_padding=”64px|64px|64px|64px|true|true” custom_padding_tablet=”128px|96px|128px|96px|true|true” custom_padding_phone=”|32px|64px|32px|false|true” custom_padding_last_edited=”on|phone” dnxt_header_margin=”||16px||false|false” dnxt_body_margin=”||||false|false” dnxt_content_margin=”||16px||false|false” custom_css_main_element=”display: flex;||flex-direction: column;” custom_css_free_form=”selector, selector .et_pb_module_inner {|| height: 100%;||}||||selector .dnxt-blurb-wrapper-outer {||\theight: 100%;|| display: flex !important;|| align-items: center;||}” dnxt_hover_bg=”dnxt-hover-fade” dnxt_hover_bg_color=”#8dc63f” dnxt_btn_text_text_color__hover_enabled=”off|hover” dnxt_btn_text_text_color__hover=”#FFFFFF” dnxt_hover_border_bg_color=”#FFFFFF” custom_css_button_wrapper__hover_enabled=”on|hover” custom_css_button_wrapper__hover=”color: #fff !important;” custom_css_body_wrapper=”text-wrap: balance;”][\/dnxte_blurb][\/et_pb_column][et_pb_column _builder_version=”4.27.4″ _module_preset=”default” type=”1_2″][dnxte_blurb _builder_version=”4.27.4″ _module_preset=”default” blurb_heading=”Language Services” hover_enabled=”0″ sticky_enabled=”0″ dnxt_btn_show_hide=”on” button_link_new_window=”on” button_link=”https:\/\/www.priviahealth.com\/notice-nondiscrimination\/” button_text=”View Form” custom_button=”on” button_text_color=”#8dc63f” button_text_color__hover=”#FFFFFF” button_text_color__hover_enabled=”on|hover” button_bg_color=”RGBA(255,255,255,0)” button_bg_color__hover=”#8dc63f” button_bg_color__hover_enabled=”on|desktop” button_border_color=”#8dc63f” button_border_radius=”5px” button_use_icon=”off” btn_show_hide=”off” border_radii_dnxt_button_borders=”on|5px|5px|5px|5px” border_color_all_dnxt_button_borders=”#8dc63f” 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text_line_height=”1.2em” global_colors_info=”{}”]<\/p>\n

Get covered for the treatments you deserve:<\/p>\n

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Patient Forms

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