The following forms are in PDF format and require Adobe® Reader® Software. If you do not have the latest version of Adobe® Reader®, please click here to download it.


New Patient Forms


Health History: To be completed by all new patients, this document provides Family Medical Center of Rocky Mount a complete overview of a patient’s health history.
Click here for Health History Form

Demographic Form:To be completed by all new patients, this document provides Family Medical Center with needed information to adequately set up the patient’s chart.
Click here for Demographic Form

Notice of Privacy Practices: This notice describes how health information about you may be used and disclosed and how you may obtain access to this information. Please review it carefully. The privacy of your health information is important to us and must be accompanied by a signed Acknowledgement of Notice for all new patients.
Click here for Notice of Privacy Practices

Acknowledgment of Notice: This form acknowledges the receipt of the Notice of Privacy Practices. The Notice informs patients of the uses, disclosures, and rights pertaining to their protected health information.
Click here for Acknowledgment of Privacy Practice Notice

Financial Policy: Click here for Financial Policy.

Self-Payment Policy: Click here for Self-Payment Policy.

Timely Filing Form: Click here for Timely Filing Form.

 

All Other Forms


Patient Instructions for 24 Hour Urine Collection

Patient Instructions for Stool Speciman Collection

Pre-Mammogram Screening Instructions/Release: These forms should be reviewed and signed prior to a mammogram screening appointment.
Click here for Mammogram Form

Medical Release: A signed Medical Release is required by HIPAA guidelines for Family Medical Center to release a patient’s medical records to another provider, insurance company, attorney’s office, etc. A Medical Release must be signed in the presence of a Family Medical Center of Rocky Mount employee so that the employee may serve as a witness to the original signature. As an alternative, the release may be signed and returned to Family Medical Center as a notarized document.
Click here for Medical Release Form

Consent for Release of Medical Information: This form is different from a Medical Release in that it authorizes Family Medical Center of Rocky Mount to release a patient’s personal medical information to another individual. It is often used for release of information to family members or care givers. A Consent for Release of Medical Information must be signed in the presence of a Family Medical Center of Rocky Mount employee so that the employee may serve as a witness to the original signature. As an alternative, the release may be signed and returned to Family Medical Center as a notarized document.
Click here for Release of Medical Information Form

Parental Consent Form: This form gives parents the option of authorizing another individual (18 years of age or older) to bring their minor child to any and all appointments at Family Medical Center. A Parental Consent Form must be signed in the presence of a Family Medical Center of Rocky Mount employee so that the employee may serve as a witness to the original signature. As an alternative, the release may be signed and returned to Family Medical Center as a notarized document. Only individuals listed on the consent form will be permitted to bring minors to appointments without the parent or legal guardian present. Please note that the temporary guardian will be permitted access to your child’s medical information and billing information until the form expires or you revoke the authorization (in writing).
Click here for Parental Consent for Minor Patients form

Employment Application

Business Agreement

Credit Card Reoccurring Payment