HTFM Patient Portal - Publicforms

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

*3 New Patients: Text Messaging

Authorization to Leave Personal Health Information via Text Message

Updox SMS is a non-secure way for you and Home Towne to communicate quickly. The primary use will be to connect with you via phone. Updox Secure texting is a HIPAA compliant software that allows Home Towne Family Medicine to communicate protect health information between you and our staff. Each patient is assigned a unique 800-888 number with a secure 5-digit pin you select for validation.

Check each box that applies. *

One- way text messaging via Updox

On my secure individualized 800-888 number assigned to me by Home Towne

I do not wish to recieve communications via text message

Mobile number *

Patient Consent

With my name below, I acknowledge and understand that this information will be kept in my medical records and the above parameters will remain in effect until revoked by me in writing. It is my responsibility to notify my healthcare provider (s) should I wish to change one or more of the telephone numbers and/or contacts listed above.

Patient Name *

Patient or Legally Authorized Person

Date of Birth *

Today's Date *

* Required field