Please complete the following forms before your first appointment or if any information has changed. These can be emailed to FMCCR23144@gmail.com or brought in with you on the day of your appointment.
New Patient Registration
Review of Symptoms
For additional forms for patients under the age of 18 click here
MAJOR INSURANCES ACCEPTED
AETNA Coventry/POS II
AETNA Medicare Advantage
BCBSTX Blue Choice PPO/Health Select
BCBS Blue Essentials HMO
BCBS Medicare Advantage PPO
Evolutions Healthcare Systems PPO
First Health PPO/CDPHP (Coventry Product)
Galaxy Health Network
Humana Medicare (TRS only)
Humana Commercial PPO/HM0/EPO
Humana Traditional (no Medicare Advantage)
IMS (Independent Medical Systems) PPO
Multiplan/PHCS/Beech Street/Texas True Choice
Tricare East Standard PPO
USA Managed Care Organization (USA)
Authorization for Release of Medical Information and Consent for Treatment
Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.
This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
Patients advise how they wish to be contacted and who they wish to be involved in their health care.
Adult Health History
For patients over the age of 18
Your annual Medicare Wellness Exam is a time for us to update your health history for the year and ensure you have received the screening services provided under Medicare. Please review and complete the forms."