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.
Central Clinic - 501.664.4810
West Clinic - 501.228.7200
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.: