Expert care in your home

Forms for new Patients

             Clicking on the links, you may download the forms to your computer so you can print them out. (Sorry, the forms cannot be filled out online for privacy reasons.) After you complete the required paperwork you can send it by mail, fax or email. We will then call you to set up an appointment.

**Required for the first visit:

– Completed Demographic Information Form

– Completed Health History Form

- Signed Agreement for Services
– Notice of Privacy Practices-last page must be signed.
-
Signed Consent for Chronic Care Management.  
This form allows Fernow House Calls to bill Medicare for the extensive "behind the scenes" time spent with phone consultations with patients, family, other caregivers, doctors, labs, and pharmacies.  It is required for us to deliver high quality service. 

Optional:

– Consent to Use E-mail

– Release of Information Form (The Release of Information Form allows me to obtain records of your care from other physicians and medical facilities.)

Again, here are the steps:

1.  Click on the link.

2.  Download the forms to your computer.

3.  Print out the forms.

4.  Complete the paperwork; make copies of insurance cards.

5.  Get the forms back to my office by mail, fax or email.

6.  You're done! The forms will become part of your medical record in my office. All information will be kept confidential.

    

1048 South Street, Dover-Foxcroft, ME 04426
      207-907-8950  Fax 1-855-677-4650

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