Our Family Health Medicine Services
New Patients
Patient Registration Form – This form will be used to obtain your demographics, emergency contact, and insurance information. This form is required to be complete upon seeing the provider.
Health History Questionnaire – This form will be used to gather your health history information including: medications, allergies, previous surgeries, family health history, etc. This form is required to be complete upon seeing the provider.
All Patients
Patient Portal Authorization – This consent form allows you to sign up or decline use of the online patient portal. You may sign up at anytime by filling out this form and mailing, emailing, or faxing this form to our clinic. New patients may bring this in along with other paperwork at initial appointment.
Authorization to Disclose Protected Health Information – This form allows Classen Family Medicine to REQUEST records on your behalf. This may be used for a variety of reason including: requesting emergency room records, previous primary care records, or specific radiology/ lab reports. Please complete all fields; leaving blanks may result in a denied request by the facility.
Release of Information Consent – This form allows Classen Family Medicine to RELEASE your records to other agencies or persons. This may include specialists, law firms, family members, or any other facility you wish to share your