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Patient Forms

Thank you for choosing Family Care Associates! Welcome to our Patient Resources Hub. Below are the essential forms designed to streamline your experience with Family Care Associates. Whether you're preparing for an appointment, authorizing medical procedures, or managing insurance matters, these downloadable forms will ensure efficient and personalized healthcare at FCA.

Medicine Dosing Chart

Easily determine and track appropriate medication dosages for your child's health and well-being.

Medicine Dosing Chart

Easily determine and track appropriate medication dosages for your child's health and well-being.

Medicine Dosing Chart

Easily determine and track appropriate medication dosages for your child's health and well-being.

HIPAA Form

Grant permission for the confidential use and release of your health information in compliance with HIPAA regulations.

HIPAA Form

Grant permission for the confidential use and release of your health information in compliance with HIPAA regulations.

HIPAA Form

Grant permission for the confidential use and release of your health information in compliance with HIPAA regulations.

Confidential Communications Form

Specify who and how you prefer to receive confidential medical information, ensuring privacy and security.

Confidential Communications Form

Specify who and how you prefer to receive confidential medical information, ensuring privacy and security.

Confidential Communications Form

Specify who and how you prefer to receive confidential medical information, ensuring privacy and security.

Authorization to Release Info to FCA Form

Enables us to access your medical history for comprehensive and personalized care.

Authorization to Release Info to FCA Form

Enables us to access your medical history for comprehensive and personalized care.

Authorization to Release Info to FCA Form

Enables us to access your medical history for comprehensive and personalized care.

Authorization to Release Info from FCA Form

Obtain and share your health records seamlessly for improved continuity of care with external providers.

Authorization to Release Info from FCA Form

Obtain and share your health records seamlessly for improved continuity of care with external providers.

Authorization to Release Info from FCA Form

Obtain and share your health records seamlessly for improved continuity of care with external providers.

Release to Insurance Form

Understand our financial policies and authorize the release of information to facilitate insurance claims efficiently.

Release to Insurance Form

Understand our financial policies and authorize the release of information to facilitate insurance claims efficiently.

Release to Insurance Form

Understand our financial policies and authorize the release of information to facilitate insurance claims efficiently.

Insurance Claim Liability Form

Complete this form to ensure your medical expenses are appropriately covered, and to address any potential claims.

Insurance Claim Liability Form

Complete this form to ensure your medical expenses are appropriately covered, and to address any potential claims.

Insurance Claim Liability Form

Complete this form to ensure your medical expenses are appropriately covered, and to address any potential claims.

Workers Comp Form

Facilitate prompt and specialized care for workplace injuries by completing this form so that we can address your health needs swiftly.

Workers Comp Form

Facilitate prompt and specialized care for workplace injuries by completing this form so that we can address your health needs swiftly.

Workers Comp Form

Facilitate prompt and specialized care for workplace injuries by completing this form so that we can address your health needs swiftly.

Authorization to Treat Minor Form

Authorize our medical team to provide necessary care to a minor in your absence, promoting prompt and effective treatment.

Authorization to Treat Minor Form

Authorize our medical team to provide necessary care to a minor in your absence, promoting prompt and effective treatment.

Authorization to Treat Minor Form

Authorize our medical team to provide necessary care to a minor in your absence, promoting prompt and effective treatment.

School Physical Form

Complete this form and bring it to your child's appointment so that we can verify his/her health status for academic requirements and/or sports participation.

School Physical Form

Complete this form and bring it to your child's appointment so that we can verify his/her health status for academic requirements and/or sports participation.

School Physical Form

Complete this form and bring it to your child's appointment so that we can verify his/her health status for academic requirements and/or sports participation.

Immunization Responsibility Form

Complete the immunization responsibility form to ensure the responsible party is billed appropriately pending insurance payment.

Immunization Responsibility Form

Complete the immunization responsibility form to ensure the responsible party is billed appropriately pending insurance payment.

Immunization Responsibility Form

Complete the immunization responsibility form to ensure the responsible party is billed appropriately pending insurance payment.

Immunization Verification Form

Provide consent for necessary immunizations to safeguard your health.

Immunization Verification Form

Provide consent for necessary immunizations to safeguard your health.

Immunization Verification Form

Provide consent for necessary immunizations to safeguard your health.

Patient Telehealth Form

Access clear guidelines for preparing and participating in telehealth appointments, ensuring a seamless virtual healthcare experience.

Patient Telehealth Form

Access clear guidelines for preparing and participating in telehealth appointments, ensuring a seamless virtual healthcare experience.

Patient Telehealth Form

Access clear guidelines for preparing and participating in telehealth appointments, ensuring a seamless virtual healthcare experience.

Child Behavioral Assessment Form - Parent Perspective Initial Visit

Complete this form for the initial visit, providing us with essential information to better understand and address your child's unique needs.

Child Behavioral Assessment Form - Parent Perspective Initial Visit

Complete this form for the initial visit, providing us with essential information to better understand and address your child's unique needs.

Child Behavioral Assessment Form - Parent Perspective Initial Visit

Complete this form for the initial visit, providing us with essential information to better understand and address your child's unique needs.

Child Behavioral Assessment Form - Parent Perspective Follow Up

Utilize this follow-up form to update us on any changes in behavior or concerns, ensuring we continue to provide tailored support for your child's well-being.

Child Behavioral Assessment Form - Parent Perspective Follow Up

Utilize this follow-up form to update us on any changes in behavior or concerns, ensuring we continue to provide tailored support for your child's well-being.

Child Behavioral Assessment Form - Parent Perspective Follow Up

Utilize this follow-up form to update us on any changes in behavior or concerns, ensuring we continue to provide tailored support for your child's well-being.

Child Behavioral Assessment Form - Teacher Perspective Initial Visit

Ask your child's teacher to share his/her observations and insights from the classroom, enabling us to form a comprehensive understanding of your child's behavior across different environments.

Child Behavioral Assessment Form - Teacher Perspective Initial Visit

Ask your child's teacher to share his/her observations and insights from the classroom, enabling us to form a comprehensive understanding of your child's behavior across different environments.

Child Behavioral Assessment Form - Teacher Perspective Initial Visit

Ask your child's teacher to share his/her observations and insights from the classroom, enabling us to form a comprehensive understanding of your child's behavior across different environments.

Child Behavioral Assessment Form - Teacher Perspective Follow Up

Ask your child's teacher to share his/her observations and insights to update us on your child's behavior in the classroom, helping us maintain a holistic perspective for ongoing support and intervention.

Child Behavioral Assessment Form - Teacher Perspective Follow Up

Ask your child's teacher to share his/her observations and insights to update us on your child's behavior in the classroom, helping us maintain a holistic perspective for ongoing support and intervention.

Child Behavioral Assessment Form - Teacher Perspective Follow Up

Ask your child's teacher to share his/her observations and insights to update us on your child's behavior in the classroom, helping us maintain a holistic perspective for ongoing support and intervention.

FCA Student Observer Questionnaire

Students in health-related fields should complete this form to request permission to shadow FCA healthcare providers.

FCA Student Observer Questionnaire

Students in health-related fields should complete this form to request permission to shadow FCA healthcare providers.

FCA Student Observer Questionnaire

Students in health-related fields should complete this form to request permission to shadow FCA healthcare providers.

Medicare Shared Savings Program Beneficiary Notice 2024

Medicare Patients - 2024 Shared Savigns Beneficiary Notice

Medicare Shared Savings Program Beneficiary Notice 2024

Medicare Patients - 2024 Shared Savigns Beneficiary Notice

Medicare Shared Savings Program Beneficiary Notice 2024

Medicare Patients - 2024 Shared Savigns Beneficiary Notice

Medicare Shared Savings Program Secondary Notice 2024

Medicare Patients - 2024 Shared Savings Secondary Notice

Medicare Shared Savings Program Secondary Notice 2024

Medicare Patients - 2024 Shared Savings Secondary Notice

Medicare Shared Savings Program Secondary Notice 2024

Medicare Patients - 2024 Shared Savings Secondary Notice

Contact

We’re Here to Serve You

Phone

217-342-7000

Fax

217-342-7002

Visit Our Patient Portal

Location

1106 North Merchant Street
P.O. Box 665
Effingham, Illinois 62401

Hours

Monday-Friday 7:00am-5:00pm
Saturday 8:00am-10:30am for acute illness only