Patient Information Update

Patient Information


Single Mar Div Sep Wid Partnered

White Black Amer. Indian Hawaiian Other No Answer

Not Hispanic/Latino Hispanic/Latino No answer

Home phone Cell phone

Male     Female     Other

Financial Information (This section only applies to 18 years of age and under)

Yes     No

Insurance Information
(Please give your insurance card(s) and identification card/driver's license to the receptionist)

Self Spouse Child Other

Self Spouse Child Other

In Case of Emergency

Family Practice Center Communication

Appointment Reminders

Home Phone Cell Phone EMail Text

Authorization to Release Medical Information
In the event you must be contacted by phone with regards to appointments, test results, referrals, or any other reason, please indicate how you wish to be contacted.

Yes     No

Do you want Family Practice Center, and all employees thereof, to be able to determine financial matters or medical care with any family members or emergency contacts? This permission will be valid indefinitely and must be revoked in writing. If so, please specify who and which information, below.
   Financial     Medical

Patient Consent for use and disclosure of protected health information
With your consent, Family Practice Center, P.C. may use and disclose protected health information (PHI) about you to carry out treatment, payment and health care operations (TPO). You have the right to review our Notice of Privacy Practices prior to signing this contract. We reserve the right to revise our Notice of Privacy Practices at any time. With your consent, Family Practice Center, P.C. may call, email or send mail to your home or office and leave a message about any items that assist the practice in carrying our TPO such as appointment reminders, insurance items and any call pertaining to your clinical care.

You have the right to request that we restrict how we use or disclose your PHI to carry out treatment, payment and health care operations. However, we are not required to agree to your requested restrictions, but if we do, we are bound by our agreement.

By signing this form, you are consenting to our use and disclosure of your PHI to carry out treatment, payment and health care operations. This consent may be revoked in writing except to the extent that we may have already made disclosures in reliance upon your prior consent. If you decline to sign this consent, we may decline to provide treatment for you.

I have read and understand the information on this form. By entering my name in the signature box below and clicking the checkbox, I acknowledge receipt and accept the terms.

Rights and Responsibilities


  • To be treated with respect, consideration and dignity at all times.
  • To receive assistance in a responsible manner
  • To receive information about your health including your diagnosis, treatment, testing or procedures and medical alternatives including associated risks that may be involved in your healthcare.
  • To know the identity and professional status of individuals providing services to you.
  • To expect that your medical records and communications will be treated in a confidential manner.
  • To refuse treatment and be advised of the alternative and likely consequences of your decision.
  • To express a complaint to the Administrator, and/or Physician.


  • To review and understand your health insurance coverage and benefits.
  • To learn and understand the proper use of your insurance plan services and procedures for obtaining coverage. This includes knowing the referral policy for your plan, laboratory restrictions and outpatient facilities covered by your plan as well as co-pay requirements.
  • To always carry your insurance plan identification card and be prepared to show it at each visit, if asked.
  • Patients will be required to pay for all services provided if insurance information is not provided by the patient at the time services are rendered or the information provided is inaccurate.
  • To treat all office personnel respectfully and courteously.
  • To keep scheduled appointments and to notify the office promptly if you will be delayed or unable to keep an appointment.
  • To pay all charges for co-payments, deductibles, non-covered benefits or services at the time of your visit, unless prior arrangements have been made.
  • To ask questions and seek clarification until you fully understand the care you are receiving.
  • To follow the advice of your medical provider and consider the alternatives and/or likely consequences if you refuse to comply.
  • To provide honest and complete information to those providing medical care.
  • To express your opinions, concerns, or complaints in a constructive and appropriate manner.

I have read and understand the office policy as stated above:

I have read and understand the information on this form. By entering my name in the signature box below and clicking the checkbox, I acknowledge receipt and accept the terms.

Financial Policy and Administrative Services Fee

We are committed to meeting your healthcare needs. Our goal is to keep your insurance and financial arrangements as simple as possible. In order to accomplish this in a cost-effective manner, we ask you to adhere to the following guidelines and choose a plan that meets your needs:

  1. It is your responsibility to provide us with your current address, telephone number and insurance information at each visit.
  2. It is your responsibility to confirm with your insurance company that our physicians participate in your insurance plan.
  3. You are ultimately responsible for payment for services you receive from our office.  Any non-payment, including non-payment of co-pays and returned checks will result in a $35 billing fee in addition to the balance owed.
  4. Canceling an appointment less than 24 hours in advance or no-showing an appointment will result in the following charges: $35 for a regular office visit, $75 for an annual physical and $100 for an ECHO, Ultrasound or Flexible Sigmoidoscopy. 3 late cancellations or no-shows in one year may result in your dismissal from our practice.
  5. The vast majority of prescription refill requests will require an office visit.  “Emergency” prescription refills maybe subject to a $35 fee.

Our office collects an Administrative Service Fee (ASF) of $6.00 on each visit or $65.00 annually to cover the cost of certain administrative services we may provide that are not covered by your insurance. Examples of these services are forms and letters such as the following:

  1. Disability/FMLA/Biometric/Health form(s)
  2. Medication/Procedural Prior Authorization
  3. School/Sports Physical/Camp form(s)
  4. Insurance related pre-certifications
  5. Life Insurance form(s)
  6. Parking/Handicap permit(s)
  7. Other miscellaneous forms
  8. Medical record reproduction

You are not required to pay the Administrative Service Fee; however, if you choose not to pay the optional fee, you will be charged for all administrative services, as needed. You will not be given a chance to pay the ASF at the time you request any administrative service above. Additionally, if you have any Administrative items pending, you may not change your designation.

I understand that with this decision, I will pay for services as I need them at a minimum rate of $60 per form/drafted letter and $35 per prior authorization per medication.

I acknowledge the terms of the financial policy and administrative service fee. I understand that failure to comply with the policies may result in my dismissal from Family Practice Center, PC.

I have read and understand the information on this form. By entering my name in the signature box below and clicking the checkbox, I acknowledge receipt and accept the terms.