Printable Forms

Forms

Emergent ACO

• Medicare Shared Savings Program Accountable Care Organizations 

Budget Agreement

• Form used for payment arrangements when a patient has an outstanding balance with our organization.

Patient Registration

• Patient Registration. Complete for New Patients and to update patient information.

Mylinks

• Mylinks portal integration

Medical Records Release

• Medical Records Release Form. Print out, complete and bring in to office.

Notice of Privacy Practices

• Notice of Privacy Practices.

Patient Authorization for Disclosure of PHI

• Patient Authorization to Disclose PHI to Family Member. Print out, complete and bring to office.

NPP Receipt and PHI Use

• Notice of Privacy Practices Receipt and Protected Health Information Use and Disclosure Consent. Print out, sign and bring in to office.

Health Insurance Coverage Default

• Health Insurance Coverage Default Policy. Print out, complete, sign and bring in to office.

Cape Fear Family Medical Care Endocrinology Patient Registration

• Cape Fear Family Medical Care Endocrinology Patient Registration

CFFMC Policy Acceptance Form

• Policy Acceptance Form for Cape Fear Family Medical Care. Print out, complete and bring to appointment.

Cape Fear Family Medical Care Endocrinology Policy Acceptance Form

• Policy Acceptance Form for Cape Fear Family Medical Care Endocrinology. Print out, complete and bring to appointment.