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Printable Documents

Should you choose to postpone registering on the Patient Portal at this time, you may print the below documents and bring them completed to your first appointment. Please note even if you complete paperwork on the portal we may need extra time prior to your visit to review and confirm.

The document below are provided in a printer friendly PDF format. A PDF viewer such as Adobe Reader is required to view the documents and can be downloaded free by clicking on the image at the bottom of the page.

Patient Profile
This form provides us with basic patient information as well as insurance information and emergency contacts. Sections 5 & 6 must be completed in order to set up a Family Account in the patient portal.

Medical History - Adult
The Medical History Questionaire provides us your medical history, alergies and medications to better treat you.

Medical History - Child Ages 0 to 4
The Medical History Questionaire for children ages 0 to 4 years old.

Medical History - Child Ages 5 to 17
The Medical History Questionaire for children ages 5 to 17 years old.

Parental Consent Form

Financial Policy
As part of our commitment to you, MPFC feels it is important that you understand your financial responsibility. MPFC's policies are listed in the linked document. If you have any questions, please ask one of our staff to direct you to the Business Office for assistance.

Privacy Practices
This notice describes how health information about you may be used and disclosed and how you can get access to this information. It is effective April 14, 2003 and applies to all protected health information contained in your health records maintained by us. We have the following duties regarding the maintenance, use and disclosure of your health records.

Records Release Forms:

Medical Records Release
Substance Abuse Records ONLY
Authorization to use and disclose health information.

Medicare Forms:

Medicare Resources
This is a list of clinics currently accepting new Medicare and Medicaid Patients. An important note- while our clinic does not accept new Medicare patients, our established patients will not be dismissed when they become Medicare eligible and sign up for Part B. An established patient is defined by MPFC as having had an appointment with us during the immediate three years prior to signing up for Part B Medicare.”

Medicare Wellness

Occupational Health Forms:

Occupational Health Medical Authorization Form- Specific to our Occupational Health Clients only. General authorization forms for our patients are above.

Diabetes Center Forms:

New Medical Park Patient Diabetes History Form

Current Medical Park Patient Diabetes Form

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