Access Intake Forms Online

Thank you for allowing Medical Advocacy and Outreach (MAO) and the team members at MAO’s Copeland Care Clinic to assist you with the management of your specialty care. MAO is dedicated to providing you and all those we serve the most equitable and compassionate relationship to improve your health and quality of life. Understanding our shared and separate expectations, maintain communication and adhering to plan objectives once defined are all critical.

To best serve you, the forms available below will need to be completed and signed by you, then presented on your first appointment. Where required, all dates should be entered in the xx/xx/xx or x/xx/xx formats. Most areas allow you to type the information into the form fields and then print for signing. An actual signature is required when/wherever required. Once submitted, all information is held in strict confidence and only released per your permission or as required  by law.

Should you have any questions relating to the completion of these forms, contact MAO (800) 1-800-510-4704. The forms require access to Adobe PDF Reader. Adobe PDF Reader can be downloaded for free.

Download Patient Demographic & Intake Form

Download Patient & Client Rights Packet

Your Rights & Entitlements Under HIPAA

NOTE: Some forms will need to be updated annually to guarantee information accuracy and to reduce any potential confusion about MAO’s expectations of you in the process and your rights as an individual receiving care.