Forms

Medical History- Required in new patient chart, identifies specific medical conditions/illnesses, current medications, and systems review

HIPAA- Required in new patient chart, confirms knowledge of privacy practices, authorizes FCA to use confidential information for the puropses of carrying out treatment and reviewing prescription histories

Confidential Communication- Required in new patient chart, specifies who is authorized to recieve medical information on the patient's behalf and identifies those authorized to pick up prescriptions.

Release to Insurance/Financial Policy- Required in new patient chart, outlines billing practices

Immunization Verification- Effective October 2011-Required to receive immunizations. Contact your insurance company, complete the questionnaire, and bring with you to your appointment

Immunization Responsibility- Required in chart of new patients under 20 years of age, advises parents/guardians of their responsibility to verify coverage of all immunizations with their insurance carrier prior to the appointment

School Physical- Use for school and/or daycare physicals.  Please print and complete the top portion of Page Two and bring to your appointment.

Sports Physical- Use for sports physical. Please print and complete Page One and bring to your appointment.

Authorization to Treat a Minor- For use when a parent is unable to accompany a minor to an appointment

Claim of Lien- For use when another party is liable for charges incurred during visit i.e. Worker's Compensation or a motor vehicle accident, this form is sent to the payer.

Liability Insurance- For use when another party is liable for charges incurred during a visit i.e. motor vehicle accident, fall, or other accident. This information is kept on file for billing purposes. 

Worker's Compensation- For use when an employer is liable for charges incurred during a visit. This information is kept on file for billing purposes. 

Authorization to Release Medical Records TO FCA- This form must be signed when transferring records TO FCA

Authorization to Release Medical Records FROM FCA- This form must be signed when transferring records FROM FCA

FCA Family Assistance Application- Please complete and return with proof of income.

Note: Forms are in Adobe PDF format.  Click here for a free download of Adobe Acrobat Reader.

 

Phone: (217)342-7000
Fax: (217)342-7002

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  • Friday: 7am- 5pm
  • Sat: 8am - 10:30am