Documents & Forms

Please print and complete these forms and fax to our office at 205-933-4429 or bring them with you to your appointment. Click form names to open in Adobe Acrobat.

For all NEW patients:
Initial Patient Information Questionnaire

For all New and Existing patients:
General Patient Registration 

For Dr. Welden's patients only:
Patient Periodic History Update

For Dr. Fitzpatrick's patients only:
Initial Patient Information Questionnaire
Patient Periodic History Update

Privacy Notice

This notice describes how medical information about you may be used and disclosed and about your accessibility to this information. Please review it carefully.

The policy of Southview Medical Group, P.C. is to protect the confidentiality, integrity and security of the protected health and personal information of our patients and to prevent unauthorized access to, or the use or disclosure of such information. We are required by law to maintain the privacy of your health information and provide you with this notice of our duties and obligations. This policy applies to all patients of Southview Medical Group, P.C.

Individually identifiable health and personal information are any information obtained by Southview Medical Group, P.C. in connection with providing healthcare treatment, obtaining payment and related health care operations. This relates to past, present or future information that Southview Medical Group, P.C. receives from you as our patient.

Southview Medical Group, P.C. collects personal information in order to learn about your medical history, medical conditions, render treatment and collect payment for our services. We gather this information from your patient forms, health questionnaires and other forms you will be asked to complete from time to time. In addition, we will assemble information based on our discussions and conversations with you, your personal representative and your family members. We may leave a message on your answering machine, voice mail, or with a personal representative to contact you about appointments or to have you call our office. We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, general condition, and payment related to your care. If you do not wish for Southview Medical Group, P.C. to use or disclose information to such individuals, you must complete a Patient Restriction Request Form.

Your healthcare plan or insurance carrier may provide information to our office. We will use this information to provide caring and quality medical care to you. Examples include diagnosis, treatment and communications such as follow up, as well as treatment alternatives or other health-related benefits. As part of our standard treatment and healthcare operations, we may share information with a facility such as a hospital, laboratory, diagnostic service or healthcare provider to efficiently coordinate your treatment plan. Your medical information may be reviewed by our medical staff for possible inclusion and referral in research studies. You will be contacted prior to the use of your information in a research study.

For contracted insurers, your information will be used for claims management and to obtain payment from your insurance carrier. As required by your insurance contractor, we will exchange paper and electronic data with your insurance carrier for activities such as eligibility, benefit and coverage determinations, precertification, utilization review and related activities. The information on or accompanying the claim may include information that identifies you, as well as your diagnosis and procedures. Our practice participates with Blue Cross and Blue Shield of Alabama InfoSolutions® and we will provide protected health information about you to this database if they manage your claim benefits. For worker's compensation, information about a work-related condition can be exchanged with the employer. We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Your information is maintained in our office in our practice management computer system. We also maintain information about you in your medical chart. Southview Medical Group, P.C. limits the access to your protected health information to those employees and business associates who need to know that information. With some limitations, you have the right to inspect, amend, copy and receive an accounting of disclosures of your medical and billing records.

We do not disclose personal information to third parties unless one of the following exceptions applies: (1) We receive explicit authorization from you to release individually identifiable information. Such authorization from you must be in writing, signed by the patient (or guardian), and give exact details regarding to whom the disclosure applies, the nature of the data to be released, the applicable dates. You may revoke this authorization by providing a written statement to the Southview Medical Group, P.C. Privacy Officer. (2) Federal, state or other applicable law requires us to share protected information or records. (3) As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. (4) Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

We are obligated to abide by the terms of this notice. If, at any time in the future, it is necessary to disclose any of your personal information in a way that is materially different from this policy, Southview Medical Group, P.C. will give you notice of the change through a mailed announcement or on your visit following the change.

With some exceptions, you have the right to review and obtain a copy of your health information. This request must be in writing, and there will be a charge to provide you with a copy of your information. You also have the right to request your records be amended, to request special accommodations and restrictions of your health information and to receive an accounting of the disclosures of your information. You have the right to request to receive confidential communications of your information. Southview Medical Group, P.C. is not obligated to agree to a requested restriction. We must receive a written request from you to administer these rights. Please speak to the receptionist for further information or to begin the process to exercise any of these rights.

If you have a complaint about the management of your health information or believe your privacy rights have been violated, contact the Privacy Officer at (205) 933-4696. You also have the right to file a complaint with the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. There will be no retaliation for filing a complaint.