New Patient Information

Your new patient registration process can go much smoother when you perform the following steps.

Please print and complete the following information prior to your first visit. We do ask that you check in 20 minutes prior to your appointment in order for us to complete the registration process.

STEP 1

Please make sure that you have all pertinent past medical records for your first appointment.

STEP 2

Please complete these two forms below. There is a copy for each partner. We cannot bill your insurance unless both you and your partner sign these forms. Due to recently established HIPPA requirements, a medical practice must have the signed consent of every person receiving medical treatment allowing the practice to bill their insurance and to release medical information related to medical claims.

Please be sure that both partners have signed these forms and given them to our office staff. Without them, we are unable to bill your insurance and must look to you to be responsible for payment. Thank you for your cooperation.

• Patient Financial Responsibility/Information Release

• Authorization for Use and Disclosure of Health Information

STEP 3

If you need to send a medical release to another clinic / facility.

• Authorization Form to Release Medical Records to FCI

STEP 4

For your review:

• Directions to FCI

• New Patient Appointment Checklist (recommended)

• Joint Notice of Privacy Practices

• New Patient Packet Insurance Referral Form

• Legal Requirement for Unmarried Couples

• Patient Advisory Council Form

• Important Notice to Subscribers of HMOI