New Patient Registration Forms
Please print and fill out each of the following forms prior to your scheduled appointment:
- Registration Forms (Demographics, Medical History, Family History, and Social History)
- ePrescribing Consent Form
- HIPAA Consent Form
- Financial Statement
- Payment Policy Agreement
New Patient Appointment Information
Welcome to Associated Family Physicians! Thank you for joining us to assist you with your healthcare needs. When making an appointment please have the following information available:
- Name and Date of Birth. If for Child, we will need Child’s Name and Date of Birth
- Photo ID, or Driver’s License.
- Guardian Name and date of birth if Parent
- Social security information of patient/parent and guardian
- Home address, city and zip code
- Preferred home or cell phone to contact patient
- Emergency Contact information
- Insurance Information
- Subscriber Information (We will need Subscriber’s Date of Birth, Social Security Information, and Employer’s Information – The subscriber is the policyholder of the insurance)
MyHillChart – Patient Portal
Join us online with MyHillChart, and take control of all your healthcare needs in one location.
With Patient Portal, patients will be able to do the following online from home:
- Send and receive secure messages to your provider
- Request medication renewals
- View, print, or download your medical records
- Receive and review documents
- View/Pay online statements (and sign up for Paperless eStatements)
- Update account information
�To enroll with MyHillChart, please speak with our Front Desk staff during your next visit to our office. They will provide you with an Access Code, which you will need in order to begin enrollment, along with instructions to complete enrollment.
You can enroll on Patient Portal here: www.myhillchart.com
For MyHillChart technical assistance, please call 1 (888) 965-8588
Useful Information
Please arrive 15 minutes prior to appointment to complete necessary paperwork, and bring with you the following:
- Current insurance cards
- State or government issued Photo ID
- List of medications or changes in medication
- List of know allergies to medications
- Immunization records
- Medical records from your previous physician
Minor children accompanied by someone other than a parent or guardian at their visit, must have a written note indicating that the accompanying person is authorized to seek treatment on your behalf. This will be required before the appointment can be conducted. In addition, our office may call you to verify that the note is authentic.
Insurance coverage varies and you will be responsible for those charges that are not covered by your policy as well as the deductible and co-pays.
We ask that you provide us at least 2 hour notice if you need to cancel or reschedule an appointment.
Release of Medical Information: If you are transferring from another clinic or practice, it will be necessary for you to sign a HIPAA-approved Medical Release of Records. Please allow ample time for these requests prior to your scheduled appointment with our office. You may obtain this release from your current provider or click here for our downloadable version.
Please schedule your next follow-up appointment with the Scheduler before leaving the office. We will be more than happy to provide you with an appointment reminder.