Patient Forms

We are ONLY accepting new patients residing in adult family homes and assisted living facilities. We do not see patients in their private homes.

If downloading registration packet, you may:

  • Fax completed forms to 855-619-1638

  • Mail forms to office address below

  • Email forms to faith-home-care@myupdox.com

Other documentation needed:

  • Copy of POA or guardianship if forms are signed by an individual other than the patient

  • Advance Directive or POLST form

  • Copy (front and back) of both primary and secondary insurance cards

  • Copy of Drivers License/Identification

  • Current medication list

  • Last provider records (if available)

Connect to Patient Portal

You can access your health records online by signing up.