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. Download and print out the blank form, fill out with a pen and bring with you to your first appointment.

NOTICE AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES

Protecting the privacy of our patients is our top priority, and required by law. Carefully read these forms before signing, should you choose to do so. These forms must be completed and returned at the patient's first visit. Please list the names of the person(s) that are permitted to access the patient's protected health information.  

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. From address changes to insurance policy number, etc. The entire form must be completed regardless of the information that has changed. 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 the Patient Portal. If you do not have an account call and request an invitation today!

Central Clinic - 501.664.4810

West Clinic - 501.228.7200

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 the Arkansas Family Care Network, P.A.:  

In case of urgent care issues after hours, please call:

The Medical Exchange 501.663.6900

For emergencies, go to your local emergency room or call 911.

CENTRAL CLINIC 

701 North University Avenue, Suite 100

Little Rock, Arkansas 72205 

501.664.4810

501.663.1256 (Fax)

WEST CLINIC 

4208 North Rodney Parham Road

Little Rock, Arkansas 72212

501.228.7200

501.228.2285 (Fax)