Forms

If you are a new patient, please complete the New Patient Check-in Sheet and Acknowledgement of Receipt of Privacy Notice Form and submit them.  We will then call you to schedule an appointment.  See also New Patient Registration page.

 

Submit forms via email, or use our secure Medical Records Upload page.

New Patients Only

The Acknowledgement of Receipt of Privacy Notice Form can be completed and signed electronically and sent to us via email or uploaded using our Medical Records Upload page.

Acknowledgement of Receipt of Privacy Notice (government-required form)
Acknowledgement of Receipt of Privacy No[...]
Adobe Acrobat document [24.4 KB]

See Notice of Privacy Practices

 

Need Adobe for your mobile device?  See link for more information:

https://acrobat.adobe.com/us/en/acrobat/mobile-app.html

Need Adobe for desktop?  See link for more information:

https://get.adobe.com/reader/

To complete Check-In Sheet online, go to New Patient Registration.  Or, if you prefer, use the downloadable form below.  It can be completed electronically and submitted via email or uploaded using our Medical Records Upload page.

New Patient Check In Sheet
Check In Sheet.pdf
Adobe Acrobat document [162.6 KB]

Transferring medical records

If you need to transfer medical records to us, you can use the form below.  It is pre-filled with our contact information.

Release of Medical Records
Authorization for Release of Info pre fi[...]
Adobe Acrobat document [24.9 KB]

Want to send us medical records right from our website?  Click here.

If you have Medicare

If you have Medicare (part B), you must sign this agreement to be seen in our office.

Medicare Private Pay Agreement with Paul Dibble MD
Medicare Private Pay Agreement-Dr. Dibbl[...]
Adobe Acrobat document [194.1 KB]
Medicare Private Pay Agreement with Alyson Van Tiem PA-C
Medicare Private Pay Agreement-Alyson Va[...]
Adobe Acrobat document [354.2 KB]

If you have Medicaid

If you (or your child) have Medicaid, you must sign this agreement to be seen in our office.

Medicaid Private-Pay Agreement
Medicaid Private Pay Agreement.pdf
Adobe Acrobat document [6.4 KB]

Simple Traditions

Family Health PLLC

18423 FM 1488 Rd Suite C

Magnolia, TX 77354

281-259-7400

Office of:

Paul Dibble MD

Alyson Van Tiem PA-C

 

Traffic in Magnolia can be surprisingly heavy; plan plenty of time for travel when coming to our clinic. See  Driving Directions

We are moving soon!

 

We are scheduled to be in our new clinic 07 JUL

 

Our new address will be:

827 S Magnolia Blvd Ste 6

Magnolia, TX 77355

 

see directions

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We do not take insurance

We accept cash, check, credit/debit cards

See our Prices

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