Forms & Handouts

Walk-In Appointment Form

This form is for NON-Harmony Mills patients who wish to have a walk-in appointment. Click here for more information about Walk-In appointments.

New Patients / Release Forms

Patient Form Packet

Individual Patient Form Pack. Please complete and bring to a new patient visit.

Family Form Packet

Family Form Pack. Please complete and bring to a new patient visit.

Newborn Information Form

Small form for newborn patients. Please complete and bring to a new patient visit.

Medical Records Release Form

If you are transferring from another primary care practice, we will need to obtain your existing records from that office. To facilitate this, please complete a copy of our Medical Records Release Consent Form (also available at our office). Once the form is completed, it will be sent to your previous provider. When we receive your records, they will be reviewed by the doctor and added to your medical chart.

Fidelis PCP Change Request Form

For ALL FIDELIS patients (new or established)!

Patients/parents enrolled with Fidelis must complete a PCP change request form.

Unless a specific provider is chosen by the patient, Fidelis will arbitrarily assign a random doctor as your primary care provider. This can happen any time you become an active patient of Fidelis, not just the first time you enroll with them (for example, if you have a lapse in your Medicaid coverage, even for just a single month)!

Fidelis will only cover visits with your PCP, so it is very important to make this change!

Welcome Letter / Policies

Welcome Letter Packet

Our Welcome Packet contains comprehensive information for you and your loved ones.

Financial Policy

Please review our Financial Policy to be aware of your rights and responsibilities.

Privacy Policy

Please review our Privacy Policy to be aware of your rights and responsibilities.

Electronic Data and HIXNY Policies Vaccine PolicyAssignment Of Benefits

Quality & Performance

Quality Improvement Memo

September 21, 2017