Northland Family Care

Patient Registration Form

Patient Information

Marital Status

Communication preference - please check at least one

Medical information may be given to

Primary Caregiver contact numbers
Patient Demographics



Veteran/Current Military

Race - check all that apply


Do you smoke or use tobacco products

Revised July 2012 - Thank you for your assistance with government regulations
Insurance Information
Do you have healthcare insurance


Northland Family Care

Medical Information Release Form

(HIPAA Release Form)
Please communicate my healthcare information in the following manner (check all that apply):
Notice of Privacy Practices

Release of Information
Release Authorization

This Release of Information will remain in effect until terminated by me in writing or three (3) years after the date signed, whichever is first.
Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.


Northland Family Care

Financial Policy

We value our relationship with our patients. To make sure there are no misunderstandings, our office policies regarding financial responsibilities for services provided are outlined below. Please review these policies and ask us if you have any questions.
  1. Current state issued picture ID and current insurance card need to be presented at the time of your appointment.  If you have an insurance with a designated Primary Care Physician, please make sure you have selected a physician in our office
  2. Copays and balances are due and payable at the time of your appointment.  If we are contracted with your insurance, you will be billed any remainder after we receive a response from them.  We accept cash, checks, Visa, MasterCard and Discover.  If you do not pay your copay at the time of your appointment you will be charged a $25 administration fee.
  3. Any balance is your responsibility after insurance processes your claim. Please be aware that some, and perhaps all, of the services provided may not be covered services, and not considered reasonable and necessary under the Medicare program and/or other medical insurance. In this case, the balance is your responsibility. If you have a question about your benefits, please call your insurance company prior to your office visit and check your benefits.
  4. Responsibility for payment for services rendered to the child/children of divorced or separated parents’ rests with the parent who seeks treatment. Any court-ordered judgement must be between the individuals involved, without including our facility or providers.
  5. Accounts become past due after 30 days. We reserve the right to send an account to collections if not paid in full.  If you cannot pay your balance in full please contact our billing department at 816-897-5810 to make appropriate arrangements.  Any account sent to collections will be considered self-pay, and no appointment may be scheduled until all current and prior balances are satisfied.  Any balance sent to collections may be subject to the 25% fee charged to NFC.
  6. All returned checks must be paid with cash or money order within 5 working days or they will be turned over to the prosecuting attorney’s office. A fee of $35 will be charged on all returned checks.
  7. Notify us at least 24 hours in advance if you cannot keep your appointment.  Failure to do so will result in a $40 charge.
  8. We do not bill workers’ compensation insurance.  We do not treat conditions from open workers’ compensation claims. 
  9. All auto accidents will be self-pay appointments.  We do not file insurance for auto accident claims, and we do not accept responsibility for collecting or negotiating insurance settlements.  Treatment resulting from auto accident will be considered self-pay.
  10. The fee for completion of FMLA forms, disability forms, etc. is $35.00 per form.

I agree to abide by the terms of the above financial policy and accept responsibility for any balance not covered by my insurance.  I authorize my insurance company to pay directly to Northland Family Care, and/or provide any information regarding the payment of my bill.  If my account becomes delinquent, I agree to pay all costs incurred in collecting the account, including a reasonable attorney’s fee if applicable. 

Patient Signature (if the patient is a minor, responsible party please sign) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.


Northland Family Care

Medical Record Release Authorization

A) I hereby authorize records FROM:

B) I hereby authorize records TO:



I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that any disclosure of information carries with it the potential for an authorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure.

I understand that the information in my medical record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Medical Records Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
I have read the information provided on this release form and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

*Subject to Fees - see below
*PLEASE READ Fee Information: Northland Family Care will provide all medical records requested from our office. We reserve the right to charge the fee schedule as set by the State of Missouri. A $22.82 handling fee, $0.53 cents per page and postage may be invoiced to you from Northland Family Care with all of the necessary directions to receive your records. By signing this authorization, you are agreeing to pay Northland Family Care for your records. In the case of continuity of care, we may transfer a minimal portion of your records directly to a physician as a courtesy.
Patient/Parent/Guardian or Authorized Representative Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.
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