Becker Family Medicine, S.C.
Forms
For your convenience and information, please reference the following forms related to our office, your care and the services provided at Becker Family Medicine. Feel free to contact us with any questions you may have.
HIPAA Form
During the course of your care at Becker Family Medicine we will create and use a variety of private health information. To ensure the security and privacy of this information we have implemented policies that outline the purposes for which we may need to use and disclose this information. Please review our Notice of Privacy Practices and feel free to ask questions about any items which you would like to further discuss.
Patient Info Form
Please complete this form prior to your first visit at Becker Family Medicine. Also, please remember to bring your insurance card and driver's license as we will need a copy of both.
Release of Records to Becker Family Medicine
To ensure we provide the best possible care, we request you bring any past medical records at the time of your first visit at Becker Family Medicine. To request your records be transferred to our office, please print the form to the right and present the completed form to your prior physician's office. Please note, the previous office may require that you pay a copying fee in order to release your records.
Release of Records From Becker Family Medicine
If you are moving, have changed insurance or need your medical records transferred to another physician's office for any reason, please complete and submit the form below to our office. We will make all attempts to comply with your request in a timely manner. Please note, Becker Family Medicine may charge a copying fee for the release of your records. You may contact our office with any questions you have regarding the release of your medical records.
Call us: 630-906-9320
Health History Form
Prior to your first visit at Becker Family Medicine, please review and complete the health history form. This is an important piece of your care and provides a great deal of information to our staff and providers. Please take your time when completing this form and answer the questions as accurately and thoroughly as possible. Bring the completed form with you when you visit our office and our staff and providers can review and answer any questions you may have.
Pediatric Health History Form
For our pediatric patients, please choose the Pediatric Health History form to the right. When providing care to children, we rely on information provided by family members and ask that you please inform us of any changes or updates to the information previously provided.
Emergency Contact Form
We are committed to the privacy and security of all of our patients. We also understand that in today's busy world there may be a time when children require healthcare and a parent is not available to accompany them to the office. Please complete this form to advise our office of others whom you authorize to accompany your child(ren) to the office and approve healthcare services provided by Becker Family Medicine. This list will also act as a contact list in case of an emergency.
Have a question about one of these forms?
Call us at (630) 906-9320!
