| Dear Patient,
Thank you for choosing the North Coast Family Medical Group to provide your healthcare needs. Below are the necessary forms that you will need to complete for your visit. By completing the forms prior to your visit, we will be able to limit your waiting time and better review your medical history. You have the choice of either mailing all of the forms to us in one envelope or bringing all of the completed forms with you to your visit. If mailing, please allow 3-4 days for delivery and we encourage you to call to confirm they have been received.
NEW! Pediatric Development Screening
Adobe Acrobat is required to print these forms.
To get acrobat, click here. |
New Patient Forms
**Please note that forms 1, 2(or 3), 5 and 6 are required for visit so you should have at least four forms in hand for visit along with your insurance card**
1. Registration Form
All lines must be completed and the form signed and dated.
2. Adult/Adolescent History Form
Please provide as much history as possible by filling out both pages fully.
3. Child History Form
For patients under age 15, please provide as much history as possible by filling out both pages fully.
4. Medical Records Release Form
This form asks your previous physician to release copies of your medical chart to us. Complete the highlighted portions and bring or send the form directly to that physician or medical group. If you have multiple physicians, you will want to make copies of the form and send one to each of your physicians.
5. HIPAA/Contact Information
The Health Information Portability and Accountability Act requires us to make this information available to you. Please print, complete, and sign this form. This form informs us of your preferences for privacy and contact. If you would like to view or print the privacy notice, please click here.
6. Member Acknowledgement of Financial Responsibility
This waiver states that you will take financial responsibility if you do not provide insurance information or the insurance is found to be invalid.
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Medical Records Forms
1. Have Forms Sent to Us
Use this form if you have records at a previous physician’s office and would like to have them transferred to our office.
2. Send Your Medical Records Elsewhere
If you need your NCFMG records copied and transferred to another physician’s office, we will send the copy at no charge as a professional courtesy to that office. If you would like to have a copy for your own records or personal use, the fees are as follows:
- Less than 20 pages = $15.00
- 21-50 pages = $20.00
- 51-70 pages = $25.00
- 71 pages or over = $25.00 + $.10 a page (for each page over 70)
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If you have any questions regarding these forms
please call us at (760) 942-0118.
We look forward to seeing you!
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