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
- 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
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.
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