PATIENT FORMS
What Is Included In Your Patient Packet?
- Form 1 Patient Registration Form – The patient registration form asks for basic information including contact information, insurance information, age, race, sex, emergency contact, etc.
As a federally qualified health center, we are required to ask questions about voter registration, household income, and other matters. We appreciate your understanding and cooperation in helping us collect this data. - Form 2 Medical and/or Dental History – Your medical or dental health history provides us with information about your family history, health concerns, medications and previous care.
- Form 3 Authorization for Release of Medical Information – The medical records release allows us to request your records from your previous primary care provider. This is not required, but it does help to give your provider a better idea of the treatment you have received.
- Form 4 Payment Policy – Our payment policy provides guidance on when payments are due, who is responsible for payments, what forms of payment are acceptable and more. Please let us know if you have any questions.
- Forms 5 and 6 Notice of Privacy Practices and Acknowledgement of Privacy Practice – These forms include our HIPAA Notice and Privacy Practices and an acknowledgement that you have received a copy of our Privacy Notice. This will need to be renewed each year.
- Form 7 Patient Bill of Rights – As a patient, you have certain rights. Some are guaranteed by federal law, such as the right to get a copy of your medical records, and the right to keep them private. This form outlines your rights and the responsibilities we expect you to fulfill as a Little River Medical Center patient.
Medical Patient Form Packet
All new LRMC medical patients must complete this form packet in its entirety. Please download the new patient packet and bring the completed forms to your next appointment.
Please complete:
- Patient Registration Form
- Medical History
- Authorization for Release of Medical Information
- Payment Policy
- Acknowledgement of Privacy Practice
- Privacy Practice Notice
- Patient Bill of Rights
Dental Patient Form Packet
All new LRMC dental patients must complete this form packet in its entirety. Please download the new patient packet and bring the completed forms to your next appointment.
Please complete:
- Patient Registration Form
- Dental History
- Authorization for Release of Medical Information
- Payment Policy
- Acknowledgement of Privacy Practice
- Privacy Practice Notice
- Patient Bill of Rights
Sliding Fee Application
Our sliding fee program is intended to make our services affordable and assure that no patient is denied care due to the lack of insurance or finances. Eligibility for the program is determined by a patient’s family size and income. An application must be completed annually and proof of income is required.
Each year patients are required to provide updated contact and insurance information.
- Annual Update Form
- Acknowledgement of Privacy Practice
- Privacy Practices Notice
Release of Medical Information
A signed release form must be obtained from a patient before their protected health information can be shared with other individuals or organizations. This is the form that is completed by new patients so that we can request records from your previous medical provider; and it is the form used so that we can forward your medical records should you ever leave the area.