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Patient Paperwork

Patient Paperwork and Forms

We have included a number of forms that you may need, whether you are a new patient or a current patient who needs to change information that we may have on file. If you don’t see the form you need here, please call our office so we can mail the appropriate forms to you in advance of your visit.

If you are a new patient, please download and complete our New Patient Paperwork before your visit. Please bring your completed paperwork, along with your insurance card and photo identification (i.e. your driver’s license) to your visit.

Note that we will ask every patient for their insurance card and photo identification (i.e. driver’s license) at every visit.

Forms Available for Download:

New Patient Paperwork (Adult)

New Patent Paperwork (Child)

 

For Medicare Patients:

Medicare Health Assessment

Million Hearts Model Beneficiary Notice

Patient Health Questionnaire (PHQ9)

 

Miscellaneous:

Accident or Injury Information

Advanced Directives

Allergy Immunotherapy Patient Contract

Insurance Waiver

Controlled Substance Contract

 

Individual Elements of New Patient Packets

Adult Health History

Child Health History

Assignment of Benefits (allowing Dunkirk Family Practice to bill your insurance company)

Authorization to Disclose Protected Information (i.e. to a spouse or family member)

Authorization to Release Protected Information (from another provider to Dunkirk Family Practice)

Notice of Health Information Practices Acknowledgement

Patient's Copy of Practice Guidelines and Financial Policy

Patient Information Form (contact details, etc.)

Red Flag Letter (how we strive to protect your identity)

Privacy Notice (how we will use your protected health information)

Wellness Visit and Office Visit Billing Disclaimer