Patient Forms

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New Patient Forms

We recommend you fill these out and bring them to your first visit.

Note: We recommend you change printer settings to black and white. Download FREE Adobe Acrobat

1. Child Intake Form or Adult Intake Form (Please complete prior to first visit)

2. New Patient Referral Survey (Please complete prior to first visit)

3. New Patient Registration Form (Please complete prior to first visit)

4. HIPPA Privacy Notice (Print, read and sign)

5. Advanced Directives information and form (Recommended for those over age 50)

6. Communication Consent Agreement (If you would like others to access your medical information)

7. What is a Physical (Information for what is included during a visit for a physical)

 


 

Information for patients about your rights and our group’s policies

1. New 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 ReportExamination Report and Certificate (For Commercial Driver, 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 of California

5. Nurse Practitioner Certification For Disability Insurance Benefits, DE 2509A

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