Patient Forms
We only serve patients residing in adult family homes and assisted living facilities. Please note that we do not provide services to patients in private homes or in clinic settings.
Important Update
We are currently accepting new patient registrations only for facilities that we already service. At this time, we are not accepting new facilities.
If downloading registration packet, you may:
Fax completed forms to 855-619-1638
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 (Required)
Advance Directive or POLST form
Copy (front and back) of BOTH primary and secondary insurance cards
Copy of Driver’s License/Identification
Current medication list (Required)
Last provider records (if available)
Connect to Patient Portal
You can access your health records online by signing up.
(Will need to include mobile number and email)