HTFM Patient Portal - Publicforms

Jump to Content

Available Forms

*1 New Patients: Consent for Treatment & Payment & Acknowledgements *2 New Patients: Cancellation & No Show Agreement *3 New Patients: Text Messaging *4 New Patients: Patient Financial Responsibility *5 New Patients: Updox Patient Portal *6 New Patients: Telehealth (VideoChat)Consent form *7 New Patients: Alternate Phone/Person *8 New Patients: Address and Insurance form *9 New Patients: Medical Records Request To Us 10) New Patients: Please Read! Thank you! 24) Patients Rights & Responsibilities 27) Telehealth (VideoChat) Consent form 31) Address and Insurance Update form 34) Consent for Payment Plan 35) Medical Records Request From Care Management Request for Medicare CCM Staff Log Patient Satisfaction Survey Prescription Refill Request

CCM Staff Log

CCM Staff Log

Started PatientClicker *

You must do this action before you proceed.

Patient Name & DOB *

Date *

Staff Member *

Method of Communication *

Communicated with *

If different than patient indicate name of individual

Name of person

If different than patient indicate name and relationship

Care Provided *

Appointment scheduled

Claims billed

Medical records retrieved

Medication reconciliation

Labs ordered per PCP

Referral ordered per PCP

Other- see below

See notes below for details or AmazingCharts imported items tab.

Time Spent (00:00:00) *

* Required field