Forms

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

HIPAA- Once accepted, 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- Once accepted, required in new patient chart, specifies who is authorized to recieve medical information on the patient's behalf and identifies those authorized to pick up prescriptions.

Release to Insurance/Financial Policy- Once accepted, required in new patient chart, outlines billing practices

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

Immunization Responsibility- Once accepted, 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

School Physical- Use for school and/or daycare physicals.  Please print and complete the top portion of Page Two and bring to your appointment.

Sports Physical- Use for sports physical. Please print and complete Page One and bring to your appointment.

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

Claim of Lien and Liability Insurance- For use when another party is liable for charges incurred during visit i.e. , fall, motor vehicle accident, or other accident. this form is sent to the payer and kept on file for billing purposes.

Worker's Compensation- For use when an employer is liable for charges incurred during a visit. This information is kept on file for billing purposes. 

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

FCA Family Assistance Application- Please complete and return with proof of income.

Ages and Stages Questionairre's

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

 

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Fax: (217)342-7002

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