Patient Paperwork
Download or Fill Out Online
You will have the opportunity to fill out paperwork online prior to your appointment. If you have not already done so, please provide our staff with your email address. This way you will receive our Phreesia pre-visit registration to complete 24 hours before your appointment. If you did not receive the pre-visit email 24 hours before your appointment, please check your email spam folder, then call our office.
If you are an existing patient looking to update your contact information, preferred contact method, emergency contacts, and list of individuals we are authorized to release your information to, you may fill out our “Restricted Use and Disclosure” form. New patients will fill this form out prior to their first appointment.
If you choose to download a PDF form and do not already have AdobeReader® installed on your computer, you can download it free by Clicking Here.
If you choose to download the PDF form(s), simply print them out and fill in the required information. Then bring your printed and completed form with you to your appointment.
Patient Forms
- Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of OBGYN Group of Eastern Connecticut) may be used and disclosed, and how you can get access to your
- Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
- Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.
- Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos
- Financial Policy (PDF) - This form advises patients of their financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
- Language Services
- Restricted Use and Disclosure Form (PDF)
- Restricted User and Disclosure Form (Online Form)
Request An Appointment
Our dedicated staff is eager to assist you! If you would like to schedule an appointment, please call our office at (860) 646-1157 or use our online form.
