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Download Forms

Please download, print and complete the forms below and bring to your first appointment at Triangle CRC.

Please note: Dr. Mumma is not in network with any third party payors, including Medicare and Medicaid.  All patients self-pay.  For more information, please see the fee schedules page.

New Patient Forms >

Newborn-Toddler Intake (0-2) >

Pediatric Intake (3-10) >

Election Not to File Health Insurance Claims Form >

ABN English 2020 – For All Medicare Patients > 

HIPAA Notice of Privacy Practices (for review – does not require signature)

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