Patient Forms

Notice of Privacy Practices (PDF) – Describes 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.

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. Autorización y Consentimiento Para el
Tratamiento

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 complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.

Language Services

For more information about our office policies and procedures click here.

Release of Records:

1. Release of records FROM Northwest Ob/Gyn
2. Release of records TO Northwest Ob/Gyn

Disability Questionnaire:

1. Disability Questionnaire

• Disability and/or FMLA forms can be dropped off at any appointment or FAXED to our office with the Disability Questionnaire attached.
• Fees must be paid prior to the completion of any and all forms.

If you have any questions, please call our office at 614-777-4801.

Having problems filling out the forms online?

If you cannot fill them out in your web browser, here are some options:

1. Try another browser (in should automatically work in Chrome).
2. Download and install Adobe Acrobat Reader DC. Make sure you uncheck any optional offers if you don’t want them (see example) before you click on the “Install Now” button.
3. Download the PDF’s to your computer: If you have an older version of Adobe Acrobat Reader, right click on the link to each form (on Mac’s hold down the control key and click on the link) and choose “Save Link As” or “Save Target As” to download the PDF to your computer. Then open the PDF’s with Acrobat Reader, fill in the forms and print them.
4. If all else fails, you can print the forms and fill them in by hand.