Patient forms.
Review and complete these before your visit to save time at check-in. Each form opens the current version hosted by Privia Medical Group — English and Spanish. You can complete most forms online through the Privia patient portal, or print them and bring them with you.
Notice of Privacy Practices
Describes how your health information may be used and disclosed, and how you can access it. Please review carefully.
Authorization for Release of Medical Information
Authorizes disclosure of your health information to a designated person, company, agency, or facility — use this to have outside imaging or notes sent to us, or ours sent elsewhere.
Authorization and Consent for Treatment
Your consent for treatment and communications (calls, emails, texts), and agreement of financial responsibility. Required before your first visit.
Patient Designated Contacts
Names the family members or caregivers we may speak with about your care. Encouraged, but not required.
Informed Consent for Telehealth Services
Explains how virtual visits work and what you are agreeing to. Review before a scheduled telehealth visit.
Health Information Exchange (HIE) Opt-Out
Optional. Submit only if you wish to opt out of sharing your information through the statewide Health Information Exchange.
Financial Policy
Advises patients of their complete financial responsibility for all medical services received, without regard to insurance eligibility or coverage determinations.
Language Services
In-office Spanish translation is available, and virtual language translation services are available during office visits. If you need language assistance, call us at (321) 972-1102 and we will arrange it for your appointment.
Manage records and appointments online
Your visit summaries, results, and messages live in the Privia patient portal.
Privia patient login →Not sure which forms you need?
Call us and we'll tell you exactly what to bring for your appointment type.
(321) 972-1102 →Forms open as PDFs hosted by Privia so you always get the current version. If your device can't open them, call the office and we'll mail or email copies. Please don't send completed forms by regular email — fax them to (321) 972-1132, complete them in the patient portal, or bring them with you.
Winter Park, FL 32789
Fax (321) 972-1132
The Renaissance Institute is a proud member of Privia Medical Group. The best doctors in our community have joined together to form Privia Medical Group (PMG), a multi-specialty, high-performance medical group that puts patients first. Our physicians are united by the mission of providing better, more coordinated care for their patients.
To learn more about Privia Medical Group and find other Privia doctors, please visit our website.