University Family Medicine Center, PA
10055 University Blvd Orlando, FL 32817
Phone 407-679-4800 Fax 407-679-0574
Text 407-679-4800
Ronald Burns, DO
Sarah Norman, APRN
Ana Greenwood, APRN
Forms and Documents
Welcome to our office: A Letter To Our Patients
See below for new patient paperwork. You can fill this out prior to your appointment if you want.
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.
New Patient Information Form
This is a mandatory form and must be filled out completely. Please include all contact information. We do use e-mail and text.
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.
Medical Release
Please use this form for medical records to be sent to another medical facility. Please make sure to fill out the address, phone number and fax number.
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.
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.
Advanced Care Directive
What is an Advanced Care Plan? Advance care planning (ACP) is the face-to-face time a physician or other qualified health care professional spends with a patient, family member, or surrogate to explain and discuss advance directives.