New Patient Forms- We recommend you fill these out and bring them to your first
(Note: We recommend you change printer settings to black and white).
Download FREE Adobe Acrobat
1. New Patient Intake Form (both adult & pediatric forms)
<- NEW PATIENT? COMPLETE THIS
2. New Patient
Survey (Please complete prior to first visit) <- NEW PATIENT? COMPLETE THIS
3. HIPPA Privacy Notice (Print, read and sign) <- NEW PATIENT? COMPLETE THIS
4. Advanced Directives information and form (Recommended for those over age 50)
Information for patients about your rights and our group's
Patient Information and policies (For your information)
Other Forms (Note: You may be able to fill out the form online prior to
printing. Rancho Family Medical Group charges a form completion fee. Please allow several days for the
form to be completed by your healthcare provider.
1. DMV Application for disabled person (You must meet one of the 8 criteria on page 2 to
qualify). Please fill out form prior to your visit with your healthcare provider. FYI: Your healthcare
provider retains the right to refuse signing the form.
2. Medical Examination Report (Green card not included- we do not have them
in our offices)
3. Physician's Health Report- (Not to be used for commercial licensing requirements)
4. Disability Insurance Claim Form for State
5. Nurse Practitioner Certification For
Disability Insurance Benefits, DE 2509A