I give Cedar Hill Medical, P.C./Cedar Hill Bayside/Cedar Hill Walk-In Clinic, permission to speak with the following people regarding my medical information. This authorization is valid until I provide Cedar Hill Medical, P.C./Cedar Hill Bayside/Cedar Hill Walk-In Clinic written revocation of it.

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT The Notice of Privacy Practices for Cedar Hill Medical, P.C. and/or Cedar Hill Bayside and/or Cedar Hill Walk-In Clinic are available for you to review. I understand that I may request a copy of the notice at any time.

ACUPUNCTURE SERVICES WAIVER I understand that my insurance will be billed for acupuncture and that I will be liable for the entire bill if my insurance does not cover these services.

I hereby state that all information listed above, to my knowledge, is accurate and give consent for treatment. I authorize the release of medical information to obtain payment of any benefits available to me to CHM/CHB/CHWI for services rendered. I authorize that direct payment of any benefits available to me be released to Cedar Hill Medical, PC for services rendered. I also understand that if my insurance company(s) denies payment, because services are not covered under my insurance plan, that I will be responsible for payment or contacting them with any questions on billing. This may include office visits, laboratory or other rendered services. I authorize the disclosure of my personal health information to obtain payment from third parties that may be responsible for such costs. I authorize the disclosure of my personal health information electronically to UPHIE.  I also understand that I may opt-out of sharing my personal health information by requesting an opt-out form from the front office staff. I have read the bottom of this registration and am aware that CHM/CHB/CHWI is a Patient Centered Medical Home.


To All Patients,

Thank you for choosing Cedar Hill Medical P.C., Cedar Hill Bayside, or Cedar Hill Walk-In Clinic to provide for your health care needs! We are striving to improve the services we offer to you.

We are currently a patient centered medical home. A patient centered medical home is a model of healthcare based on a personal relationship between the patient, provider and the patient’s care team. Whatever the medical needs – primary, preventive care, acute care, chronic care, or end-of-life care – the patient has a medical “home”. A single, trusted provider and care team, through which continuous, comprehensive and integrated care is provided.

In order to best serve your needs, we must work as a team. Below is a description of your responsibilities and those of the provider.

Patient Responsibilities

  • Make healthy decisions regarding your health
  • Prepare for and keep scheduled visits or reschedule visits in advance
  • Tell your doctor about any changes in your health status
  • Take all medications as prescribed and follow the provider’s orders
  • End every visit with a clear understanding of your provider’s orders, medications, treatment goals and follow up
  • Ask questions if unclear
  • Come to Cedar Hill Medical P.C. / Cedar Hill Bayside / Cedar Hill Walk-In Clinic or call for all medical concerns, unless it is a medical emergency

Provider Responsibilities

  • Listen to patient’s health concerns, symptoms and questions
  • Explain diseases, treatments and results in an easy to understand manner
  • Assist patient in medical decision making based on current medical research
  • Give clear directions about medications and treatments
  • Send patients to trusted experts, when needed
  • End every visit with clear instructions about orders, treatment goals, and follow up
  • Keep all patient information private
  • Provide 24 hour access to medical care, same-day and walk-in appointments, whenever possible
  • Provide instructions on how to meet your health care needs when the office is not open

Hours of Operation: Monday – Friday 8-5 EST

Walk-In Clinic: Gladstone: Monday – Friday 9-5 EST
Bark River: Monday – Friday 9-5 EST

We look forward to working with you to maintain and improve your health.

The Providers and Staff at:
Cedar Hill Medical, P.C., Cedar Hill Bayside &
Cedar Hill Walk-In Clinic