Patient Forms
The forms below are provided by Privia Medical Group. Please review them before your visit. Each link opens the most current version of the PDF on the Privia website.
Notice of Privacy Practices
Describes how health information about you may be used and disclosed, and how you can access your individually identifiable health information.
Authorization for Release of Medical Information
Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
Authorization and Consent for Treatment
All patients must provide consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.
Preferred Contacts
Patients are encouraged to complete and return the Preferred Contacts form, though it is not required.
Financial Policy
Advises patients of their complete financial responsibility for all medical services received, without regard to insurance eligibility or coverage determinations.
Language Services
Free language assistance services are available for patients with limited English proficiency or who are deaf or hard of hearing. Please call our office at (678) 454-3331 to request an interpreter for your visit.
Notice of Nondiscrimination
Tate Medical Associates of North Georgia is a proud member of Privia Medical Group. Care Center–specific forms are not duplicative of, nor contradictory to, the Privia Medical Group forms listed above.