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.

Registration Packet (All documents below)

New Patient Registration

Medical Records Release Form

Information Release

Chronic Care Management Consent

Medical History Questionnaire

Notice of Privacy Practices

Telemedicine Consent Form

Office and Financial Policies

AI Scribe Consent Form

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.