Hours of Operation
Monday - Friday 8:00 am - 5:30 pm
(252) 443-3133
Christ is at the heart
of our practice
As Christian providers, we care about the needs of you and your family and strive to provide superior patient care.
Pediatrics – Adolescents
Adults – Seniors
Forms
The following forms are in PDF format and require Adobe® Reader® Software.
If you do not have the latest version of Adobe® Reader®, please click here to download it
New Patient Forms: Health History: To be completed by
all new patients, this document provides Family Medical Center of Rocky
Mount a complete overview of a patient’s health history. Click here for Health History Form Notice of Privacy Practices: This notice describes how health information about you may be used and disclosed and how you may obtain access to this information. Please review it carefully. The privacy of your health information is important to us and must be accompanied by a signed Acknowledgement of Notice for all new patients.
Click here for Notice of Privacy Practices Acknowledgment of Notice: This form
acknowledges the receipt of the Notice of Privacy Practices. The Notice informs patients
of the uses, disclosures, and rights pertaining to their protected
health information. Click here for Acknowledgment of Privacy Practice Notice All other forms:
Patient Instructions for 24 Hour Urine Collection Patient Instructions for Stool Speciman Collection Consent for HIV testing Pre-Mammogram Screening Instructions/Release: These forms should be reviewed and signed prior to a mammogram screening appointment. Click here for Mammogram Form Medical Release: A signed Medical Release is required by HIPAA guidelines for Family Medical Center to release a patient’s medical records to another provider, insurance company, attorney’s office, etc. A Medical Release must be signed in the presence of a Family Medical Center of Rocky Mount employee so that the employee may serve as a witness to the original signature. As an alternative, the release may be signed and returned to Family Medical Center as a notarized document. Click here for Medical Release Form Consent for Release of Medical Information: This form is different from a Medical Release in that it authorizes Family Medical Center of Rocky Mount to release a patient’s personal medical information to another individual. It is often used for release of information to family members or care givers. A Consent for Release of Medical Information must be signed in the presence of a Family Medical Center of Rocky Mount employee so that the employee may serve as a witness to the original signature. As an alternative, the release may be signed and returned to Family Medical Center as a notarized document. Click here for Release of Medical Information form Employment Application
