Patient Forms

Please Read: We do not service private homes.

We are ONLY accepting new patients residing in adult family homes and assisted living facilities

Please download and complete all required forms below to set up as a new patient to our practice.

Fax completed forms to 855-619-1638. You can also mail forms to our office address. 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.