ATTENTION MD  Oren Mason MD      
Forms
TELEPHONE AND REMOTE FOLLOW UP VISITS

The forms necessary for these visits can be printed out, completed and faxed to (877) 411-1871 or mailed to our office.  We need the completed form prior to the appointment time for your visit. 

If you have the computer skills, the forms can be completed in Microsoft Word and emailed to omason@attention.md  If you use a different word processor, remember to save the completed form in .doc or .pdf format. 

Please note that you will need to obtain pulse, weight and blood pressure readings prior to telephone visits.  These can be from your physician's office or home equipment.

Child Follow Up Form (Word DOC form)  (PDF form)      Parent or teacher update of progress since last visit. 

Adult Follow Up Form (Word DOC form)  (PDF form)     This form is appropriate for patients 18 years of age and older.  Copies can be given to an observer--a spouse, partner or close friend--who can give a second perspective on progress.  
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PERMISSION TO SHARE PROTECTED HEALTH INFORMATION

Do you need to give Dr. Mason permission to discuss your care (or your dependent child's care) with someone else?

Permission to disclose confidential information  (Word DOC form)  (PDF form)  

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CONFIDENTIALITY NOTICE: To protect confidentiality, test faxes and test emails are required.  We use a secure email system and will respond to your email with a return email message.   Your replies to our emails are encrypted and satisfy current confidentiality standards.  Test faxes simply ensure that you are connecting properly with our equipment. 


NEW PATIENTS

The paperwork needed for your first visit can be printed out, completed and faxed to (877) 411-1871 or mailed to our office.  It must be submitted before your first appointment will be scheduled.

If you have the computer skills, the forms can be completed in your word processor and emailed to omason@attention.md  Please remember to save the completed form in .doc or .pdf format, not in .pages format.

CHILD HISTORY FORM for children 12 and under.                                       Word document     PDF document       

TEEN HISTORY FORM for teens ages 13-18 unless enrolled in college.         Word document     PDF document     

**Children and teens need at least one teacher evaluation.  

Teacher evaluation form                                                                           Word document     PDF document   

 
COLLEGE HISTORY FORM for college students ages 18-25 years old.           Word document     PDF document     

ADULT HISTORY FORM for adults 19 and older unless enrolled in college.    Word document    PDF document     

**Attention MD needs permission to discuss your care (or your child's care) with your physician, therapist or school

Permission to disclose confidential information                                           
Word document    PDF document  

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