Tricity Family Medicine & Urgent Care

Available Forms

0.1: Appointment Request 1: PATIENT DEMOGRAPHIC FORM 2. HIPAA FORM 3: FEES, PAYMENT & BILLING POLICIES 4: CREDIT CARD ON FILE POLICY 5: OFFICE POLICIES 6: LAB BILLING POLICY 7. Lab Result Follow-up question 8. Prescription Refill Request 9. Referral Request/ Question A1. Billing Question Address/Contact Information Update Form Adult Annual Wellness/ Physical Exam Pre-visit Form Blood Pressure Log Blood Sugar Readings Cancer Screening Services Record Update GAD-7 Generalized Anxiety Disorder Healthcare Questions Insurance Update Form Password Request The Mood Disorder Questionnaire (mdq) Z: Patient Satisfaction Survey - Care at Tricity Family Medicine Z: Patient Satisfaction Survey - Community Referral Process Z: Patient Satisfaction Survey - Referral Process (Coordination of Care) Z: Specialist/Hospital Care Coordination Form

A1. Billing Question

Patient's First Name *

Patient's Last Name *

Patient's Date of Birth *

Patient's Account #

If not available leave blank.

Date of Service in question *

Questions/ Concern *

Preferred Contact Name *

Preferred Call Back# *

Please allow us 2-3 business days to review your request. For questions about your patient responsibility under your health insurance plan, please call your insurance directly. We are obligated to collect per your benefits coverage processed by your insurance plan. For matters requiring immediate attention about billing error or collection notice, please call 919-261-6446 to talk to our collection specialist.

* Required field