New PatientsColumbiana Family Care Center gladly accepts new patients. Please contact our office with the following information:
- Patient's legal name
- Patient's address and telephone number
- Patient's valid insurance information
- Patient's date of birth
- Patient's referring physician
- Patient's emergency contact
- Name of financially-responsible person, including his/her legal name, address and telephone number
For your first visit, please:
- Print and complete the following forms and bring them with you:
Authorization for Disclosure of Protected Health Information Form
Health History Form
HIPAA Release Form for Adults or HIPAA Release Form for Minors
- Bring your current insurance card(s) with you if you have health insurance coverage. If you are unable to bring an insurance card and we cannot verify your insurance coverage, we may ask you to reschedule your appointment. It is our policy to collect co-pays, deductibles, co-insurance amounts and any outstanding balances at the time of service.
- Bring a list of your current medications and pill bottles with you.