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

31) Address and Insurance Update form

Name *

Date of Birth *

Address

Address 2

City

State

Zip code

Home Phone

Cell Phone

Email Address

Insurance Name

Policy ID number

Group Number

* Required field