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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.
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