FHMS Patient Information

Patient Forms

Patient Forms

Below is a list of forms available to you in PDF format for your convenience. They are separated into 3 categories, Health Information Forms, Billing and Insurance Forms and Other.


Depression Screening - Adults and Children Forms
You may be asked by your healthcare provider to complete this depression screening form prior to your visit. You may give it to your nurse on the day of your visit. (Note: Page 1 is adult, Page 2 is children)


Blood Glucose Log Form
Do you have diabetes? We provide this useful blood glucose log for you to print and keep track of your own blood sugar levels. Please bring your log to your routine visits with your healthcare provider so he/she can evaluate your blood sugars.


Blood Pressure Log From
Do you have high blood pressure? We encourage regular monitoring of blood pressure. Feel free to click on the log form above and print it out for your own use and bring it to your routine visit to share with your healthcare provider.



Billing and Insurance Forms

 

Application for Hardship Discount – Sliding Fee Program
We offer a discount on provider services for uninsured patients. If you are uninsured and would like to apply, please complete this form prior to your visit.


Workers Compensation Injury Form
If you have had a work-related injury and have an open Workers’ Compensation case, this form should be completed before your first visit with your healthcare provider.


MVA/Accident-Injury-Sprain-Strain Form


NYS Motor Vehicle No Fault Assignment of Benefit Form



Other Forms


No-Show Waiver Petition
Use this form if you believe you deserve special consideration for a “no-show” or “late-cancellation” fee.


Complaint Form
Do you have a complaint, we want to hear about it so we can improve our processes. Just fill out this form and hand it to one of our receptionists at the time of your visit.


Medical Records Release Form
We are sometimes required to obtain your authorization before releasing your medical records outside our offices. For example, if you decide to transfer your care to or from our office, you will be required to fill this form out so your medical records can be sent to or from our office.


Health Care Proxy Form
This form gives the person you choose as your agent the authority to make all health care decisions for you, including the decision to remove or provide life-sustaining treatment, unless your say otherwise in this form.


Do Not Resuscitate Order Form (DNR)
This form (DNR) tells medical professionals not to perform CPR. This means that doctors, nurses and emergency medical personnel will not attempt emergency CPR if the patient’s breathing or heartbeat stops.



Prescription Pick-Up Authorization


Notice of Privacy Practices
This Notice describes how medical information about you may be used and disclosed, and how you can access this information.


2014 Polar Plunge Registration Form
Polar Plunge - Saturday, February 14, 2015 at Lakeside Park - Mayville, NY. Check-in starts at 10:30am. Plunge at 12:00pm.