New Patient Forms

Please fill out our new patient forms PRIOR to your first appointment at our office. Bring your completed forms to your in-office visit or email them to us at appointments@selenaellismd.com.

If you would like to update who we share your health information with, please complete the HIPAA form below:

Notice of Open Payments Database

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at:

https://openpaymentsdata.cms.gov