Top Doctor Award New Patient Health History Health History Form for New Patients to bring completed to their first appointment. Medical Records Release TO our office Form used to have your medical records from other doctors sent to Jefferson Internal Medicine Notice of Privacy Practices This notice describes how medical information about you may be used or disclosed. Bristol-Myers Squibb Patient Assistance Information and Application Information and application for the Bristol-Myers Squibb Patient Assistance Program. sanofi-aventis APPEAL FOR MEDICARE PART D If you have Medicare Part D you will need to complete this form along with the application. Both forms can be submitted together. sanofi-aventis Patient Assistance Information and Application Information and application for the sanofi aventis Patient Assistance Program. Merck Patient Assistance Application For more information, a link to the Merck Patient Assistance page is available from this page. Sanofi Patient Assistance Application Patient to complete page 2 of application to apply for assistance from Sanofi. PACE Prescription Assistance Information Contact information for PACE. Patient Survey Patient Survey