Many of the PDF forms below are supplied to you when you made your appointment but are provided here for backup. If you are having trouble viewing the form, please make sure a readily available free PDF Reader is installed on your device and updated. Please feel free to contact us with any questions regarding the forms.
Appointment Related Forms:
New Patient:
Forms: Please remember to download the forms to your computer, fill them out, and then send them back. If you fill out and close online, all of your input will be lost. You must download and save it to your local before you can send it back to us.
- Patient Consent Form - must be on file for all patients.
- Telemedicine Consent Form - must be on file if you have a telemedicine appointment.
- Medicare Patient Consent Form - must be on file if you have Medicare.
- General Contact Information - fill out online in our portal or you may use this PDF.
- Privacy Notice
- New Patient History Questionnaire - adult
- New Patient History Questionnaire - child
- In Network Request Letter - Please contact us for this letter which you can send directly to your insurance to help increase your reimbursement.
- Referral Form - can help with insurance reimbursement.
- After Appointment - designed to answer questions that may arise after the appointment.
- Personal Representative Form - to allow us to discuss issues and make appointments through another person if you are over 18 yrs old.
Insurance: Please contact us for an In Network Request Letter that you can directly provide your insurance. Any reimbursement will be increased if the request is granted by your insurance. Supplying your insurance with a referral to our practice by your primary provider may provide additional support even if your insurance may not require a referral.
Your PCP may use the following verbiage when discussing your referral with your insurance. In addition, we have a referral form listed above that you can supply them as well:
XXXXX (patient name and DOB) has or is suspected to have a connected tissue, mitochondrial, metabolic, or other inherited disorder that requires a specialist in those fields. We have referred this patient to Dr Kendall (NPI# 1881658300) at VMP who is a biochemical geneticist recognized as a leader in and is one of only a handful of specialists in the US who are focused and knowledgeable in this field. There are no such specialists within a reasonable radius or who have openings without a long waiting list. Please remember that not all geneticists are the same nor have the skills as Dr Kendall has to properly diagnose or treat this patient.
Follow up Appointment:
- Follow up Questionnaire - fill out online in our portal or you may use this PDF.
- Patient Consent Form
- Telemedicine Consent Form
- Medicare Patient Consent Form - must be on file if you have Medicare.
- General Contact Information - for updating contact info. May be filled out online in our portal or you may use this PDF.
- In Network Request Letter - Please contact us for this letter which you can send directly to your insurance to help increase your reimbursement.
- After Appointment - designed to answer questions that may arise after the appointment.
- Personal Representative Form - to allow us to discuss issues and make appointments through another person if you are over 18 yrs old.
Travel Related Forms:
The following form provides lodging, travel, fun things to do locally, restaurant tips, and directions to our clinic:
Medical Record Related Forms:
- Release Medical Records to VMP - The following form is helpful to use when you are gathering the records to supply to us.
- Release Medical Records From VMP - releasing records to another office: Please understand we take releasing medical records very seriously in today's environment and their release has become a very complex process due to all the rules and regulations that are involved. We prefer patients release their own records as they see a need. Records for those patients seen within 14 months are supplied for free to the patient and for a fee mandated by the state of Georgia for each 3rd party. If the patient has not been seen within 14 months there is a fee as mandated by the state of Georgia for providing records to the patient and or any 3rd party. It can take a week or more to release records to 3rd parties or a day or two when releasing them to the patient.
- Correction/Amendment of PHI - this form is required on file if there are any changes to our clinical note after it has been released. Once a clinical note is released, any further changes or modifications require the note to be identified as AMENDED along with identification of what has changed.