Download Forms

+ Notice of Health Information Privacy Policies DOWNLOAD PDF
+ Notice of Privacy Acknowledgement DOWNLOAD PDF
+ Patient Rights & Responsibilities DOWNLOAD PDF
+ HIPAA Consent Form DOWNLOAD PDF
+ Refill Policy DOWNLOAD PDF
+ Patient Update Form DOWNLOAD PDF
+ EVFM Intake DOWNLOAD PDF
+ Financial Policies and Agreements DOWNLOAD PDF

**You may be required to fill out additional forms once arriving for your appointment***



EVFM Patient Demographics
Full Name
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Date of Birth
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Gender
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Phone
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Cell Phone
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Martial Status
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SS#
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Email Address (*)
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Address
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City
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Zip
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Secondary Contact
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Emergency Phone #
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Employer
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Employer Phone#
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Employer Address
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Spouse's / Parent's Name
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Spouse / Parent Phone #
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Responsible Party Information:

Policy Holder's Name
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Policy Holder's DOB
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Policy Holder's Address
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Policy Holder's City and Zip
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Relationship to Patient
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Policy Holder's SS #
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Policy Holder's Email
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Policy Holder's Phone
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Insurance Information:

Name of Insurance Company
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Policy #
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Group ID #
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ID #
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Copay $
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Billing Address
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Billing City & Zip
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Secondary Insurance Company
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Secondary Policy #
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Secondary Group ID#
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Secondary ID #
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Secondary Copay
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Do you have an Advance Directive/Living Will?
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Are you an ORGAN DONAR?
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Agreement
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  EVFM PNPI TMC