Online Forms

Federal HIPAA Consent Forms - Explanation

When you register today, you will be asked to complete a form which asks you to give permission or consent to Moreland Family Medicine. This form is necessary due to the implementation of a federal law called the Health Insurance Protection and Portability Act (HIPAA). This law requires Moreland Family Medicine to obtain your consent to perform the following acts.

General Consent - This consent gives us the ability to function on your behalf performing normal medical/business duties. Examples: We need to talk to your insurance company so that your bills are paid or a procedure is approved. We may need to talk to the hospital or another medical office to provide notes or test results.
Consent To Release Information to Family Members - Under HIPAA we are not allowed to give test results to family members such as to your spouse. Many times patients will have a spouse call for results because they are working, without this consent we will not be able to give any information to family members.
Consent to Leave Messages with Household Members or on Answering Machines - Under HIPAA we cannot leave specific messages for patients. Often we need to leave reminders regarding lab results, appointment times or the need for a patient to call a physician or provider. Without this consent we cannot leave messages at your house.

Please take the time to complete the Patient Consent Form. We will honor and protect your medical information and pledge to make sure that all information remains confidential. These consents maybe revoked at any time by providing a written letter to Moreland Family Medicine revoking any one or all of the three consents. Print out forms, fill out and bring with you to the clinic.

HIPAA Forms:
Patient Privacy Consent Form (PDF)
Patient Privacy Notice (PDF)

Other Forms:
Health History Form (PDF)
Patient Registration Form (PDF)
Patient Information Release Form (PDF)

WIAA Sports History and Physical Form (PDF)
Student-Athlete Alternate-Year Physical Card (PDF)

CDL Physical Exam Form (PDF)
Permanent Disability ID Card Application (PDF)
Worker's Compensation Form (PDF)
Disabled Parking Identification Cards (Permanent Disability) (PDF)
Disabled Parking Identification Card (Temporary Disability) (PDF)

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Moreland Family Medicine Associates, S.C. 717 W. Moreland Boulevard, Waukesha, WI 53188 Phone: (262) 542-9100 FAX: (262) 542-7366

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Moreland Family Medicine Associates, located in Waukesha, Wisconsin, is family practice offering pediatrics, physical therapy, sports medicine, Osteoporosis care, Bone Densitometery testing and more health care services to southeastern Wisconsin residents. Moreland Family Medicine Associate serves patients in Waukesha County and surrounding areas, including Waukesha, Delafield, Oconomowoc, Menomonee Falls, Pewaukee, Mukwonago, New Berlin, Brookfield, Muskego, Germantown, Jackson, West Bend and Waterford.

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