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Patient Paperwork

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 Packet Adult

New Patient Packet Child

For Medicare Patients:

Medicare Wellness Form

Million Hearts Model Beneficiary Notice

Miscellaneous:

Accident or Injury Information

Advanced Directives

Allergy Immunotherapy Patient Contract

Controlled Substance Agreement

Individual Elements of New Patient Packets

Adult Health History

Child Health History Form

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

Auth for Info Disclosure (i.e. to a spouse or family member)

Authorization for Release of Medical Information To DFP (from another provider to Dunkirk Family Practice)

Health Information Practices and Privacy Notice 040517 (how we will use our protected health information)

Notice of Health Information Practices Acknowledgement

Patient's Copy of Guidelines and Patient Financial Policy

Patient Information Form (contact details, etc.)

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

Wellness Visit and Office Visit Billing Disclaimer