Privacy & Forms

Privacy

We are committed to the privacy of our patients. We protect all health information in compliance with the law. We keep a record of all patient interactions with the clinic, and details of the services provided. Patients may request a copy of their personal health record, and we may amend those records at the patient’s request, if they are found to be inaccurate. We do not disclose protected health information to anyone, unless given permission by the patient, or when the law authorizes or compels us to do so.

The Privacy Practices notice describes how information about you may be used and disclosed and how you can get access to this information.  Please review it carefully.

Registration Forms

The Registration Forms below can be opened and filled out on your computer, or printed and handwritten before your appointment.  All forms are also provided in the clinic and can be completed after you arrive.  You do not have to fill them out beforehand.

  • New Patient Packet:  Please complete these forms if you have never been seen at Family Health Center before, or it has been over 24 months since you were seen last.  Bring the completed forms with you to your appointment.  If the form has an asterisk (*), the form is patient information is for you to keep.
    • Registration Form (PDF or Word)
    • Slide Fee Application (PDF or Word)
    • Consent to Treat (PDF or Word)
    • Release of Protected Health Information (PDF or Word)
    • *MyChart Information (PDF)
    • *Welcome Packet English (PDF)
      • *Welcome Packet Spanish (PDF) – Coming Soon!
    • *Privacy Practices English (PDF)
    • *Privacy Practices Spanish (PDF)
  • Annual Review:  Please complete these forms if it has been 12 months since your last appointment.  Bring the completed forms with you to your appointment.  If the form has an asterisk (*), the form is patient information is for you to keep.
    • Annual Consent and Slide Fee Application (PDF or Word)
    • *MyChart Information (PDF)