Forms

Medical History- Required in new patient chart, identifies specific medical conditions/illnesses, current medications, and systems review

 

HIPAA- Required in new patient chart, confirms knowledge of privacy practices, authorizes FCA to use confidential information for the puropses of carrying out treatment and reviewing prescription histories 

 

Confidential Communication- Required in new patient chart, specifies who is authorized to recieve medical information on the patient's behalf

 

Release to Insurance/Financial Policy- Required in new patient chart, outlines billing practices

Immunization Verification- Effective October 2011-Required to recieve immunizations. Contact your insurance company, complete the questionnaire, and bring with you to your appointment

Immunization Responsibility- Required in chart of new patients under 20 years of age, advises parents/guardians of their responsibility to verify coverage of all immunizations with their insurance carrier prior to the appointment

Physicals- For use of daycare, school, and sports physicals.  Please print and complete the top portion of page two and bring to appointment 

 

Authorization to Treat a Minor- For use when a parent is unable to accompany a minor to an appointment

 

Claim of Lien- For use when another party is liable for charges incurred during visit i.e. Worker's Compensation or a motor vehicle accident

Authorization to Release Medical Records TO FCA- This form must be signed when transferring records TO FCA

Authorization to Release Medical Records FROM FCA- This form must be signed when transferring records FROM FCA

Note: Forms are in Adobe PDF format.  Click here for a free download of Adobe Acrobat Reader.