Assiginack Family Health Team

Forms

Due to the high demand for form completion, there may be a wait time.

Forms

We understand that at times, various forms or letters may be required to assist you with your healthcare needs.

Please do not just drop an envelope off at the reception desk.

We have a forms clerk that looks after all forms. You will need to be seen in the Family Health Team. Please fill out all the information that you are required to fill and sign the form.

We will not accept any form without your signature on it.

You will be contacted when your form is completed. Forms are a third party billing. You may be responsible for any costs that are involved in the filling out of the form.

Medical Records

As HIPAA guidelines, copies of medical records must be requested in writing.

To ensure your privacy, a form for release of medical information must be complete prior to receipt of these materials. All patients can request a copy of their medical records one time, free of charge. Additional copies may be requested at a cost of $0.75 per page. The law allows Medical Offices 30 days to complete the request of records. We will try our best to get the information copied in a timely manner.

Patient Passport

This Health Passport encourages you to record your continuing health. It is intended to be used as a guide for ongoing health, wellness and follow-up of any Chronic Disease Process.

This passport gives you information about early signs of possible concerns regarding your health that you need to discuss with your Family Health Team Providers.

Download:

Patient Passport (FILL AFTER PRINTING)

Patient Passport (FILL ONLINE)

HOW TO USE YOUR PASSPORT

The Health Passport is designed to help you record important information. Keep it on hand, take it with you when you visit your Doctor or other Health Care Professional. Please make sure all entries are made accurately.

Your Family Health Team is available to assist you when entering your initial data

Health Care Directive (Living Will)

INSTRUCTIONS TO PERSONS COMPLETING THIS DIRECTIVE:

  • You may wish to discuss this directive with your doctor before completing it.
  • Be sure the directive clearly expresses your personal wishes, ie., if there is any section you do NOT wish to include, cross it out and initial the cross-out. There are special instructions in part 5 for expressing personal wishes.
  • The directive should not be signed until you are in the presence of your witness.
  • Your witness is confirming that you are of sound mind and making this directive of your own free will.
  • Keep this original document in a safe but accessible place known to your family, caregiver, and doctor.

Download:

Health Care Directive

Call Us