Patient Forms

Clinton Medical Clinic

Name:

DOB:

Requested MD/PA/NP

Phone:

Insurance:

Employer:

Current Provider:

Seen Previously at CMC?

Yes No

CMC MD:

Any Family Members at CMC:

Reason for Change:

Major Surgery

Medications

Step 1 -> Return to CMC Business Office:

Check with Business Office regarding previous balance. All previous balances must be paid-out prior to accepting patient.
Please Check:

Zero Balance:

Outstanding Balance of:

Step 2 -> MD PA/NP Review:

Step3 -> Contact Patient:

Accepted (No Outstanding Balance) Declined Nursing staff to contact patient.
Accepted With Outstanding Balance: Nursing staff to forward form to appropriate Account Rep who will contact patient.

Patient Contacted ->

Date

Staff:

Step 4 ->

Appointment Scheduled For:

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