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NEW PATIENT FORMS


PRIMARY CARE
 PATIENT INTAKE FORMS

For Primary Care patients, please  complete the following intake forms under Primary Care Patient Intake Forms. Once you set your appointment, print out forms, complete them and bring the forms on the day of your appointment.

Also, if available, bring a list of all your current medications with dosages, your recent medical records, labwork and immunization records from past 2 years to your first appointment.

.PRIMCARY CARE INTAKE FORMS


WELLNESS & WEIGHT LOSS INTAKE FORMS

For clients enrolling in our Wellness & Weight Loss program, please complete the following forms under Wellness and Weight Loss Intake Forms and bring to your appointment

Also bring a list of your current medications with dosages and your most recent labwork with you to your first appointment.


WELLNESS & WEIGHT LOSS INTAKE FORMS




INTEGRATIVE / HOLISTIC HEALTH INTAKE FORMS

For clients enrolling in our Integrative / Holistic Health Programs, please complete the following forms under Integrative / Holistic Health Intake Forms  and bring to your appointment.

Also, if available, bring a list of all your current medications with dosages, your recent medical records, labwork and immunization records from past 2 years to your first appointment.

New Patient Registration Form.doc

HIPPA-Privacy Form- PDF.pdf

Financial & Health Services Policy-PDF.pdf

Holistic Health Forms- PDF.pdf

Holistic Health Services Contract.pdf



**FOR ESTABLISHED PATIENTS**
 Every 3 , 6 and 12 month time periods in which you are a patient at Eze Family Health Center, we want to monitor how well your overall health has improved. Complete the Health Status  form at the end of your 3rd, 6th and 12th month with us and we will be able to track your health improvement progress over time.

Health Progress Survey- PDF2.pdf


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INSURANCE & PAYMENTS

At Eze Family Health Center, we understand the difficulties in securing affordable Health Insurance Coverage. We offer an affordable, fee-per-service options for self-pay patients. Call us for more details at  (240) 419-3865.

We accept patients on PPO plans that are free to see medical providers outside of their network.
 
Eze Family Health Center will soon accept all major insurance carriers.  Call our office for more details or email at 
info@EFHCenter.com .

**We accept insurance for Primary Care and Holistic Health Services only**

Insurance Carriers accepted:

   Aetna

   Cigna

   Priority Partners


   Multi-Plan   

   Carefirst / BlueCross BlueShield  

   United Healthcare

   Coventry Health




At Eze Family Health Center, we understand the difficulties in securing affordable Health Insurance Coverage. We offer affordable, fee-per-service options for our self-pay patients. Call us for more details at (240) 419-3865.

Eze Health Center will soon accept more insurance carriers. If you have an insurance that we currently do not accept, please call our office  to find out the status.

*** Before making an appointment, please call our office to confirm that your insurance is accepted ***

*** If your insurance is not accepted by our office, you are welcome to schedule an appointment as "self-pay" and will assume all financial responsibilities***

All Major Credit Cards are accepted including Visa, Mastercard, American Express and Discover. No checks accepted.

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