Limited English Proficiency Check In Documents

For translation of the below, please select the appropriate language in the drop down in the top left corner.

The following require patient signature at time of visit:



Patient medication history is a list of prescription medicines that our practice providers or other providers have prescribed for you. Pharmacies and health insurers are sources of this history.

The information collected is stored in the practice EMR and becomes part of your personal medical record. Medication history is very important in helping healthcare providers treat your symptoms and to avoid potentially dangerous drug interactions.

It is vital that you and your provider discuss ALL of your medications to insure that your medication history is 100%. All over-the-counter drugs, supplements or herbal remedies should be reported to your provider as they may not be included in the prescription history.

I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers.



HIPAA (Health Insurance Portability and Accountability Act)

HIPAA (HIPAA: Acronym that stands for the Health Insurance Portability and Accountability Act, a US law designed to provide privacy standards to protect patients’ medical records and other health information provided to health plans, doctors, hospitals and other health care providers) requires doctors’ offices and other health care providers to protect the privacy of your personal health information.  Personal health information (PHI) is “individually identifiable health information” held or transmitted by a covered entity or its business associate, in any form or medium, whether electronic, on paper, or oral.

This form is to be utilized as a means to identify any person whom you permit to communicate with your health care team here at Family Medical Care Community Health Center. Your provider, along with your care team will be permitted to communicate freely with identified individual (s) until you wish for this authorization to be discontinued.

You may revoke this authorization at any time by notifying the staff of Family Medical Care.  Any additions to this HIPAA AUTHORIZATION must be made in person and contain your signature.



Authorization for Treatment of a Minor

Minor’s Name and Date of Birth

As parent/legal custodian/legal guardian (specify which) of the above named minor, I (we) hereby grant permission to Family Medical Care, to evaluate and involve him/her (specify by circling) in treatment as deemed appropriate.

I (we) understand that this authorization is subject to revocation at any time, except to the extent that action has been taken in reliance thereon.

I (we) have read this form and agree to the above conditions.

Signature Parent/Legal Custodian/Legal Guardian