Patient Information

Form Downloads

• Patient Information Form (Form #31654, Rev 1/23)
• Patient Information Form (SPANISH) (Form #31655, Rev 4/20)
• Parent / Guardian's Consent for Treatment, Information Sharing, and Financial Agreement (Form #31647, Rev 5/20)
  
  
• Adult Patient Information Form (Form #31957, Rev 10/17)
• Adult Patient Consent for Treatment, Information Sharing, and Financial Agreement (Form #31648, Rev 12/20)
• Adult Patient Consent for Treatment, Information Sharing, and Financial Agreement (SPANISH) (Form #31666, Rev 5/20)
  
  
• Authorization for Release of Information (Form #33760, Rev 3/24)
  
  
• TSSAA Physical Examination Form

• Additional Measles Vaccine Consent Form (Form #34639, Rev 4/25)

Accepted Insurances

Please call if you have any questions regarding accepted insurances.

• TennCare: BlueCare
• TennCare: AmeriGroup
• TennCare: United Healthcare Community Plan
• Aetna
• United Healthcare
• BCBS of Tennessee
• Cigna Healthcare
• Cigna Connect
• Tricare
• Humana
• Multiplan/PHCS

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