New Patient Demographic Form
This form is to collect your basic information. The top section of this form is the information on the person being seen. The second section of the form is information on the person who is the insurance policyholder or information for the person responsible for the patient if the patient is a minor. The last section of the form is information as to who is living in the household.
Patient History Forms
The patient history form is needed so our providers can see what your past medical history has been like. There are two forms listed, one form is for adults and one for pediatrics.
Pediatric History Form
This form is for patient ages 17 years and younger. Please fill out the information on their history best to your remembrance. We realize that if your child is in their later teenage years, it may be hard for you to remember some of the information we’re asking.
Adult History Form
This form is for patient ages 18 years and older.
Financial Policy Form
This form is for you to read and sign. If you have any questions regarding our Financial Policy, please contact our Billing Specialist at the above phone number and press extension 275.
Acknowledgment of Consent Form
This form is for you to also read and sign. This is giving us consent to give you medical treatment, bill your insurance, and acknowledging you received a copy of the HIPAA form.
HIPAA/AIDS Information Sheets
This form is for your information only. You do not need to bring this form with you on your visit. Family Medical Center is required by law to give you a copy of this information. The HIPAA form is to make you aware of the HIPAA laws and who you can contact should you feel your HIPAA rights have been violated. We are required to give you information regarding the AIDS virus because we are a Rural Health Clinic.
If you have any questions about these forms or anything else, please feel free to contact our office at 270-524-7231 and press option 1 for help. Please click the link below to view the New Patient Information Forms.