Office: 404-351-7467  

Patient Portal (MyChart)

Patient Forms

Forms Packet

Save time in the waiting room! Complete these forms packet before your visit and bring them with you to your appointment.

Non-Medicare Patients

Non-Medicare Patient Forms Packet

Notice of Patient Privacy

Insurance & Self-Pay Policy

Piedmont Internal Medicine is committed to providing high-quality care. At this time, our practice cannot accept uninsured patients or those who wish to be seen on a self-pay basis.

To establish care and receive services, patients must have active health insurance coverage accepted by our practice.

We understand that insurance circumstances can change and appreciate your understanding of this policy. If you have questions about whether we accept your insurance, don’t hesitate to contact our office before scheduling an appointment.

Good Faith Estimate

Medicare Patients

Medicare Patients Forms Packet

Notice of Patient Privacy

Medicare Records Release

New patients, we must have any pertinent past medical records. Please verify that these records are faxed to us from your previous physician’s office before your appointment.

Medical Records Release Authorization

Individual Forms

Remote Care Management Consent Form

Chart Pro Release Authorization

Patient Grievance Procedure

If you need an individual form from the forms packets above, each can be found below.

Non-medicare Packet Forms

Patient Information

Medical History Questionnaire

Financial Agreement

Consent and Releases

Medication Prior Authorization Request

Medicare Packet Forms

Medicare Advantage Patient Notification Letter

Medicare Physical Exams

Patient Information

Medical History Questionare

Medicare Health Risk Screening Tool

Financial Agreement

Consent and Releases

Medicare Secondary Prayer Questionnaire

Medication Prior Authorization Request

Telemedicine Instructions

Whether using the MyChart app or the MyChart website, the following instructions will guide you through the process.

Telemedicine Instructions