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Make an Appointment

Please complete the following forms before your first appointment or if any information has changed. These can be emailed to FMCCR23144@gmail.com or brought in with you on the day of your appointment.

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  • New Patient Registration

  • Contact Preferences

  • Financial Policy

  • Health History

  • Review of Symptoms

  • For additional forms for patients under the age of 18 click here​

Patient Forms

MAJOR INSURANCES ACCEPTED

AETNA Coventry/POS II

AETNA Medicare Advantage

Apostrophe

Assurant Health

BCBSTX Blue Choice PPO/Health Select

BCBS Blue Essentials HMO

BCBS Medicare Advantage PPO

Cigna/Great West

Cigna International

Evolutions Healthcare Systems PPO

First Health PPO/CDPHP (Coventry Product)

Galaxy Health Network

GEHA

HealthSmart

Humana Medicare (TRS only)

Humana Commercial PPO/HM0/EPO

Humana Traditional (no Medicare Advantage)

IMS (Independent Medical Systems) PPO

Medicare

Multiplan/PHCS/Beech Street/Texas True Choice

PHCS

Tricare East Standard PPO

UHC Medicare

USA Managed Care Organization (USA)

Zelis

 

Patient Request To Have Medical Records Transferred to Another Health Care Provider

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Authorization for Release of Medical Information and Consent for Treatment 
Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. 


Financial Policy
This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
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Contact Preferences
Patients advise how they wish to be contacted and who they wish to be involved in their health care. 
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New Patient Registration


Adult Health History
For patients over the age of 18

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Review of Symptoms

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Medicare Wellness

Your annual Medicare Wellness Exam is a time for us to update your health history for the year and ensure you have received the screening services provided under Medicare.  Please review and complete the forms."

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