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.
For New Patients:
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
Practice Guidelines and Financial Policy
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
Patient Health Questionnaire PHQ-9
For Medicare Patients:
Medicare Shared Savings Program ACO 2023
For Medicare Wellness Visits:
Patient Health Questionnaire PHQ-9
Miscellaneous:
Accident or Injury Information
Allergy Immunotherapy Patient Contract