Leo Toupin MD New Patient Info Page

In order to expedite the registration process, please click and fill
out all of the following new patient forms prior to your first office
visit. This will allow us to better serve you and to save you time
prior to your visit. You may return the completed forms to us by:
1.) Hand carrying to the first office visit, 2.) Faxing to (512) 977-
8301, or 3.) Clicking Submit at the bottom of each form (follow
prompts to create a digital signature). Please bring all originals
with you for your initial visit, along with your current insurance
card(s) and valid driver’s license or identification card.

		Patient Re gistration Fo rm
		Patient History Questionnaire
		Notice of Privacy Practices
		Office Policies
		Controlled Substance Agreement
		Release of Medical Records
		E-mail Agreement
		Services Waiver Agreement

Please feel free to contact our office if you have any questions regarding these forms at (512) 977-8300.

Financial Information /Insurance:

Our office participates with many health insurance companies in
the Austin area. We encourage you to be an informed
consumer by understanding your coverage, how to access
information from your carrier, and which ancillary providers, e.g.
lab, and x-ray facilities, participate with your plan. When there
are changes, either in demographics or insurance coverage, it
is your responsibility to inform the office and supply supporting
documentation. We require that any applicable deductible, co-
insurance or co-payment be paid at the time services are
rendered. Payment may be made by cash, authorized check,
Visa or MasterCard. There is a $30.00 fee for returned checks.

Please refer to our office policies or contact our office if you
have any questions regarding our financial policy. Our staff
will be happy to assist you.

We look forward to your visit!

Our goal is to provide quality,
efficient and cost effective
primary patient care.

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Policies

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Reader.

Welcome to Capital Primary Care and thank you
for making an appointment with our office!

New Patient Information Page

Leo Toupin MD PA

Phone:
(512) 977-8300