Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.
"I and my wife have been to this practice twice each for urgent care issues. All four times we were well treated by both the staff and the medical professionals. Our medical needs were appropriately addressed leading to resolution of our various ailments. Thank you, Joe Moore!"
Please click on the following links to download necessary forms you will need as a new patient of Chickahominy Family Physicians.
Financial Policy Forms
Disclosures to Family and Friends
Written Acknowledgement Forms
Privacy Practices Form
Patient Information Form
Authorization of Consent for Medical Treatment + Medicare Authorization Form
Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente
Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento
Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos
Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.
Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)
Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)