Forms
Progressive Family Care has provided the following forms for you to fill out at your convenience prior to your office visit.
New Patient Forms
Demographics Form:
this form provides the office with patient address, phone number, insurance information, etc.
Designation of personal rep and HIPAA form:
this form allows you to designate someone besides yourself that can get your records or someone the office can contact regarding your medical issues. This form also allows you to determine if we can leave detailed information at the home phone number, work phone number, and/or cell phone number. This form must be signed.
Get Medical Records Sent to Us:
please fill out this record request form if you have a previous primary care physician and are transferring your care to Progressive Family Care.
Policy On Office Visits:
this form indicates that you are aware of our policies regarding health insurance, workers’ compensation, self pay patients and auto insurance/third party liability. This form must be signed.
Workman's Compensation Forms
Workman's Compensation Form:
if the office visit will be billed under workers’ comp please fill out or have employer fill out form prior to office visit. Please inform receptionist when scheduling appointment that the appointment will be billed under workman's comp.