Family Medicine Registration Form

Register Online
  • Patient's Information

  • Emergency Contact Information (A local person)

  • HIPAA Disclosure (People other than yourself)

  • Insurance Information (Please provide all applicable insurances. Not providing all the insurance information will result patient being discharged from the practice)

  • CONSENT FOR EXAMINATION, MEDICAL TREATMENT AND CONDITIONS OF EXAMINATION.

  • INFORMATION CONCERNING FILING A CLAIM WITH YOUR INSURANCE COMPANY.

  • Authorization for request of medical records.

  • TO:

  • I Hereby authorize the release of information from the medical record of:

  • Please Release Information To:

  • Preferred Medical Group: Centralized Fax: (334) 664-0466

  • Informed Consent for Release of Confidential Information

  • I understand that I may revoke this consent in writing at any time except to the extent action has been taken. I understand that this consent will expire 90 days after the date of my signature unless otherwise specified. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal Privacy Regulations.

New Patient
Registration
Patient
Portal
Virtual
Tour