Forms

New Patient Form Packets

Please select the appropriate packet to print and complete. You are not required to complete any other forms on this page, as these packets contain all necessary forms for new patients. 

New Patient Packet, Non-pregnant

New Patient Packet, Pregnant


 

Established Patient Forms

Important Note: On March 2014, we launched a new Electronic Medical Record system. To ensure that all patient information is accurate in our new system, all patients who are being seen for the first time since our “go live” in March of 2014 must complete our New Patient Forms.  This includes patients who were pregnant at the time of our transition. We apologize for the inconvenience and thank you for your patience.

If you have had an appointment with Tepeyac Family Center since March 2014, your information may be updated in our new EMR. Please complete one of the following forms.

Patient Packet, Non-pregnant

Patient Packet, Pregnant

 


 Complete List of Forms


 

Patient Registration and Updates

Patient Registration Form

Address Update Form:  If your address of residence has changed.

Insurance Update Form:  If your insurance has changed, or if you have received a new insurance card.


 

HIPAA Forms

Every new patient needs to read the Privacy Notice, sign the Receipt, and return the receipt to the front desk at their initial visit. Established patients should review the Privacy Notice and sign an updated receipt annually or when the Notice is updated. You may sign the Privacy Notice electronically at Tepeyac’s Practice Portal at tfc.portalforpatients.com if you register for our secure messaging site. Please read The Privacy Notice, which was last updated in August 2014.

Privacy Notice and Receipt Form:  Please print and sign.

You may also be interested in optional forms mentioned in the Privacy Notice that you can obtain by clicking on the links below or at tfc.portalforpatients.com at the bottom of the Patient Privacy Practices page. These include:

Authorizations and Preferences Form: Please complete and sign if you wish to identify the persons allowed to receive your healthcare information or identify persons that should never receive your healthcare information. You also may note specific preferences for contacting you (e.g., cell phone, e-mail).

Fundraising Options Form:  Tepeyac and/or its owner, Divine Mercy Care, may use limited patient information to contact you for fundraising purposed to benefit Tepeyac. You may opt out of fundraising or opt back in using this form.

List of Disclosures Request Form:  You may request us to provide a list of disclosures made of your information which were not for purpose of your treatment, payment, or Tepeyac operations, and not otherwise made at your request. Please use this form to ask us to account for such disclosures.


 

Medical History Forms

Medical History Form:  For new patients.

Medical History Update Form:  For established patients who are not pregnant, or who are less than 8 weeks pregnant.

OB Survey Form:  For new and established patients coming in for their first OB appointment (generally 8 weeks).


 

Medical Records Release Forms

Records Release TO Tepeyac Family Center Form:  Use this form if you need your medical records sent from another office TO Tepeyac.

Records Release FROM Tepeyac Family Center Form:  Use this form if you need medical records released FROM Tepeyac Family Center to another practice. Please note that it takes several days for records release requests to be processed. There may be a charge for this service.


 

Other Forms and Services

Disability Forms:  If you have your own forms to be completed for your disability claim, please bring them into the office. Requests for disability forms have the following charges:

Charge for completing forms is $25.00 ($5.00 for each additional page after page one).

An additional $20.00 fee will be assessed for forms completion without a 24-hour notice.

A document replacement fee for lost prescriptions, forms, or letters will be assessed at $30.00 per item.