Forms and Documents

Welcome to our office:  A Letter To Our Patients

 

Please print and complete the information form, medical history form and HIPPA form at your earliest convenience, and then bring them 20 minutes before your appointment. 

We require your driver's license/ ID and insurance card.   

Insurance questions?  We have some info here, or you can email us if you have further questions. We're excited to help you!

New Patient Information Form

This is a mandatory sheet and must be filled out completely.  Please include all contact information so we can communicate most effectively.  We do use e-mail and text. 

Adult Information

HIPAA Form

Health Insurance Portability and Accountability Act of 1996 requires patient consent for use and disclosure of protected health information. This is a law to safeguard your personal information.

HIPPA

Medical Release

This form is for the patient if they ever need to access their records or want them to be sent to another medical facility for any reason. If this form is being used for the purpose of transferring forms to a specialist, please make sure to fill out the address, phone number and fax number.

Medical Release Forms

Adult Medical History

This history allows us to understand your current and prior health conditions.  It helps us identify any future health problems that may come from your family history.

Adult Medical History

Pediatric Form

These forms are for the patients under the legal age of 18, and must be signed by their guardian in order for them to be seen as a patient. We collect their medical history, as well as their general information.

Pediatric Forms

© 2019 by UFMC, PA

Family Practice 

Office Contact Information

10055 University Blvd

Orlando, FL 32817

Tel: (407) 679-4800

Fax: (407) 679-0574

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