HTFM Patient Portal - Publicforms

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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

Care Management Request for Medicare

CCM Medicare Patient Log

Patient Name *

Date of Birth *

Staff Member you wish to handle your request *

Please note if your provided is needed, our staff can communicate your request to your PCP.

Preferred Method of Communication *

Communicate request with *

If person is different than yourself please indicate name of individual in the next box

Name of person

If different than patient indicate name and relationship

Care Requested *

Appointment scheduling

Medication refills

Bloodwork

Specialist referral

Medical records retrieval

Insurance issues

Add details in the notes box below

Please provide detailed information in the box belowregarding your request

Details *

* Required field