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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.
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New Patient Registration
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Contact Preferences
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Financial Policy
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Health History
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Review of Symptoms
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For additional forms for patients under the age of 18 click here​
Patient Forms
MAJOR INSURANCES ACCEPTED
AETNA Coventry/POS II
AETNA Medicare Advantage
Apostrophe
Assurant Health
BCBSTX Blue Choice PPO/Health Select
BCBS Blue Essentials HMO
BCBS Medicare Advantage PPO
Cigna/Great West
Cigna International
Evolutions Healthcare Systems PPO
First Health PPO/CDPHP (Coventry Product)
Galaxy Health Network
GEHA
HealthSmart
Humana Medicare (TRS only)
Humana Commercial PPO/HM0/EPO
Humana Traditional (no Medicare Advantage)
IMS (Independent Medical Systems) PPO
Medicare
Multiplan/PHCS/Beech Street/Texas True Choice
PHCS
Tricare East Standard PPO
UHC Medicare
USA Managed Care Organization (USA)
Zelis
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.
Financial Policy
This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
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Contact Preferences
Patients advise how they wish to be contacted and who they wish to be involved in their health care.
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Adult Health History
For patients over the age of 18
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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."
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