Patient Information Forms
For your convenience, you may download and complete necessary forms at home and return to us or bring to your first visit. Included below are Assured Direct Care enrollment forms and new patient medical and treatment documents for your first appointment. A complete medical history is necessary to allow your Assured Direct Care providers to assess your needs, make diagnoses and provide treatment recommendations.
Please fully complete the forms forms and verify accuracy of the information. This will help your provider to better know your personal medical history, individual needs, medications and allergies.
Click the links below to open the forms using Adobe Acrobat. Print and complete the forms, and bring them with you when you come in for your appointment. (Please don’t email this information.)
New Patient Forms
There may be additional forms to complete when you have scheduled an appointment. You may need to come early for your appointment to complete them. Please bring your ID and any insurance information to each appointment (medical, workman’s compensation or from a motor vehicle accident).
In addition, please bring a list of your medications and the current dosages. If you do not bring this information or are late for your appointment, we reserve the right to reschedule your appointment. We appreciate your care in completing this advance preparation for your appointment.
Medical Records Forms
Assured Direct Care Forms
- Assured Direct Care Enrollment
- Assured Direct Care Membership Agreement
- Automatic Billing Authorization Form
- Medicare Private Contract