Patient Information
Patient Forms
Please print, complete documents 1 & 2 and have available for Dr. Wichman on the day of appointment:
- Patient Forms – 1 copy
- Medicare Private Contract – 2 copies. Fill in top of first page and bottom right corner of the 2nd page.
If you have any questions, you can ask them when Dr. Wichman arrives for the visit.
Authorization for Release of Information* – only needed if you request transfer of records.
Notice of Privacy Practice optional
Please note: the forms are in PDF format. If you cannot read the PDF, please download the free Adobe Acrobat Reader from the Adobe website.
