Forms

Maintaining accurate and comprehensive medical records is very important to your care. The forms below can be downloaded by clicking the blue buttons marked "Download this Form"

 
 

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.

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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.

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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.


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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.

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Health Information Release

This form is for patients who choose, for any reason, to have their health information transfered from their current provider over to Arkansas Family Care Network, P.A.:

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Announcements

DOT Physicals are
now available!
Little Rock Family Practice Clinic – Central is pleased to announce we now have an APRN on site who is certified to perform DOT physicals. We are excited to offer this service for our patients who need them. Call today to get on the schedule!
Get your FLU shots
We strongly encourage our patients, particularly those at risk, to get a flu shot every year. The shots will be administered 8:30 a.m. to 11:30 a.m. and 1:00 p.m. to 4:00 p.m. daily, Monday through Friday. They are not available during our Saturday urgent care clinic.
Insurance
Many insurance policies include wellness benefits covering all or a substantial part of an annual physical. We encourage you to take advantage of this opportunity to keep yourself well.
No Show Policy
Patients who are not able to keep their appointments are asked to provide timely notice of cancellation prior to their appointment time. Therefore, effective October 1, 2013, Little Rock Family Practice will institute a formal policy regarding appointment cancellations.
Learn More
After hours
In case of an urgent care issue after hours please call the Medical Exchange at 501-663-6900. For emergencies go to your local emergency room or call 911.