Skip to content
  • Call Us: (859) 626-7794
Pay Online

Madison Family Clinic

  • Home
  • About Us
    • Services
    • Providers
  • Contact
  • Patient Forms
  • Helpful Advice
Menu
  • Home
  • About Us
    • Services
    • Providers
  • Contact
  • Patient Forms
  • Helpful Advice

Patient Forms

Patient Portal

We know how annoying it can be to visit the doctor’s office and fill out the required forms. Here you will find the forms where you can download, print and fill out at home.

New Patient Adults

  • Agreement of Financial Responsibility
  • Consent to Care
  • Health History
  • Lifetime Beneficiary Claim Authorization
  • Medical Visit Authorizations
  • Medicare MSP Inquiry
  • Notice of Privacy Practices
  • Patient Rights & Responsibilities
  • Notice of Privacy Practices Acknowledgement & Consent
  • Registration & Health Assessment
  • Authorization for Release of Information
  • Non-Discrimination Policy

New Patient Pediatrics

  • Agreement of Financial Responsibility
  • Consent to Care
  • Health History
  • Medical Visit Authorizations
  • Notice of Privacy Practices
  • Patient Rights & Responsibilities
  • Notice of Privacy Practices Acknowledgement & Consent
  • Registration & Health Assessment
  • Authorization for Release of Information
  • Non-Discrimination Policy

General

  • Patient Satisfaction Survey
madison-family-clinic-logo-w
  • Call: (859) 626-7794
  • Fax: (859) 626-7764
  • 2161 Lexington Rd, 1st Floor, Suite 5, Richmond KY 40475

HOURS

  • Monday: 8:30 - 5:00
  • Tuesday: 8:30 - 6:00
  • Wednesday: 8:30 - 5:00
  • Thursday: 8:30 - 5:00
  • Friday: 8:30 - 5:00
  • Saturday - Sunday: Closed

LINKS

  • Contact
  • Pay Online
  • Patient Forms
  • Helpful Advice
  • Facebook
  • Instagram

INSURANCE

We accept Medicaid and Medicare, private and commercial insurance. For quality care close to home, rely on the family services at Madison Family Clinic.

© 2023 All rights reserved Madison Family Clinic

Website Designed by Dedicated Web Design - Berea, KY