Forms

Our Registration Package makes it easy to be new here!

We are delighted to welcome you to the Riverside family. Please find set out below our New Patient Registration Package and our Record Release Forms.

For all Patients

  1. Riverside General Information Packet opens new window (Also available in Spanish opens new window)
  2. Riverside Notice of Privacy Practices opens new window (Also available in Spanish opens new window)
  3. Nondiscrimination Notice & Access to Communication opens new window (Also available in Spanish opens new window)
  4. Optum-Riverside Website Privacy Policy (opens new window)opens new window
  5. Optum-Riverside Terms of Use (opens new window)opens new window

For Our New Adult Patients

  1. Adult New Patient Welcome Letter opens new window (Also available in Spanish opens new window)
  2. Adult New Patient Registration Forms opens new window (Also available in Spanish opens new window)
  3. Adult Medical History Form opens new window (Also available in Spanish opens new window)
  4. Adult Cancer History Form opens new window (Also available in Spanish opens new window)
  5. Adult Depression and Alcohol Questionnaire opens new window (Also available in Spanish opens new window)

For Our New Pediatric Patients

  1. Pediatric New Patient Welcome Letter opens new window (Also available in Spanish opens new window)
  2. Pediatric New Patient Registration Forms opens new window (Also available in Spanish opens new window)
  3. Pediatric Newborn Questionnaire (opens new window)opens new window

 

Co-pay Policy

All co-pays in accordance with your insurance benefits policy must be collected at the time of service, including co-pays that are required for follow-up sick visits and visits to refill chronic medication.

Patient Balances

All patient balance are due within 30 days of services rendered. Please contact our billing department at 551-257-7030 to make your payment today!

Record Release Form

If your records are at a different practice and you would like to join Riverside Medical Group, please complete this form and send it to the Office Manager at the office that you visit.

Click here (opens new window)opens new window for a copy of our Patient Record Release Form.