FORMS FOR NEW PATIENTS
NEW PATIENT INFORMATION
This form is for all new patients to fill out and bring to the clinic upon their first visit. This form gives you the option of (1) filling out the form on your personal computer, printing it and bringing it with you, or (2) printing out a blank form, filling it out with a pen and bringing it with you.
NOTICE AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES
Protecting the privacy of your medical information is required by law and we respect and carefully abide by that law. You should carefully read these forms – and then acknowledge your acceptance of their conditions by signing should you choose to do so. These forms must be completed and returned to the clinic at the time of a patient’s first visit. You should list names of person(s) that are permitted access to your (or the patient’s) protected health information. No information can or will be shared with anyone who is not listed on this form.
FORMS FOR RETURNING PATIENTS
INFORMATION CHANGE FORM
The Information Change form should be filled out when there is any type of change in the patient’s information, whether it is an address, policy number, etc. The entire form must be completed regardless of the information that has changed. Please present the form upon your arrival to see a doctor. Keeping your information accurate and current allows us to provide you with better health care and ensure your claims are paid promptly.
MEDICATION REFILL REQUEST
This form is for patients who wish to request refills for their medications.
This form may only be completed through our Patient Portal. If you do not have an account call and request an invitation today!
MEDICAL RECORDS REQUEST
This form is for patients who choose, for any reason, to have their medical records transferred to any other location or health care provider.
HEALTH INFORMATION RELEASE
This form is for patients who choose, for any reason, to have their health information transferred from their current provider over to Arkansas Family Care Network, P.A.
MEDICARE ANNUAL WELLNESS VISIT
This form is for patients scheduling their annual Medicare wellness visit.
SELF-ASSESSMENT OF DIABETES MANAGEMENT
This is a self-assessment for for patients managing diabetes.