Call Us: 1-870-892-4467

Forms

Maintaining accurate and comprehensive medical records is very important to your care.

Patient Information Forms

All new patients will need this information completed for their first visit. This set of forms includes patient information, insurance information, our financial policy, privacy practices and patient consent. Please print the form and fill out the information and bring it with you to the clinic for your first appointment.

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Release of Medical Records

An authorization form is required when you are requesting copies of medical records or asking that we disclose your health information to 3rd parties. If you need your record copies to be sent to another health care provider for treatment purposes, you may download the following form and return to our office.

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Notice and Acknowledgement of Privacy Practices (HIPAA Policy)

Protecting the privacy of your medical information is required by law and we respect and carefully abide by that law. You should carefully read these forms – and then acknowledge your acceptance of their conditions by signing should you choose to do so. These forms must be completed and returned to the clinic at the time of a patient’s first visit. You should list names of person(s) that are permitted access to your (or the patient’s) protected health information. No information can or will be shared with anyone who is not listed on this form.

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Main Clinic

2901 Medical Center Drive
Pocahontas, AR 72455
p. 870-892-4467
f. 870-892-4407

East Clinic

1601 Market Drive
Pocahontas, AR 72455
p. 870-892-4467
f. 870-892-4407

After Hours

In the case of an emergency always call 911.
If you have an emergency medical condition that needs to be addressed after hours, please refer to the emergency room services at Five Rivers Medical Center.
Poison Control: 1-800-222-1222