Forms/Privacy Practices

Membership Agreement (Appendix 1 in the document best describes in layman’s terms what is in the membership) 


Agree to the Membership/Sign up Forms

(Please complete these pages to officially enroll. I need these pages even if you complete the online enrollment.)

Fax to 888-511-5674, eMail to ask@YaphaMD.com or mail to Yapha Physician Services, LLC, P.O. Box 4858, Pineville, LA 71361


Membership Cancellation Form

(To cancel your membership, simply fill out this form and return via email, fax or mail.)


Form to request Medical Records from your Previous Provider to be sent to YaphaMD.  


HIPAA Notice of Privacy Practices Information on your privacy rights 

Sign this: HIPAA Acknowledgement Form for Patient Signature  (I need this form signed by the patient or parent/guardian.)

HIPAA Privacy Restrictions for Paying in Full Upfront This explains your HIPAA privacy rights if you wish to restrict your health care information from your insurance or health plan for payment or other purposes. This requires upfront payment in full for the restriction to be valid.

Complete this: YAPHA HIPAA Health Plan Restriction Request for Paying in Full Upfront If you wish to enact your HIPAA Rights to Restrict your health information from your health insurance or health plan, you  must complete this form and pay in full upfront for any services received.