Effective **06/17/24** we will be reinstating our no show and cancellation within 24 hours fee. All patients who no show or cancel within 24 hours of their appointment will have a charge of $50 added to their account. This fee does not go to insurance and will be patient responsibility. There will be exceptions for emergent situations.


Cape Fear Family & Med One Care's Business hours are

Monday through Friday 8AM- 5PM

Printable Forms

Printable/Interactive Forms

Important Patient Information

The patient registration packet can be downloaded and filled in using your personal device: PC, Laptop ETC. you can then print it off without having to fill it all in by hand, you will just need to sign any parts requiring a signature.




Below is a list of medical record release forms. Should you have any questions about which one is appropriate, please feel free to contact our medical records department at (910) 323-3183 ext. 108.

A group of people are sitting at a table looking at a piece of paper.

Forms

Emergent ACO

  • Medicare Shared Savings Program Accountable Care Organizations 


Budget Agreement

  • Form used for payment arrangements when a patient has an outstanding balance with our organization.


Patient Registration

  • Patient Registration. Complete for New Patients and to update patient information for all practices.



Endo Medical History Form

  • In addition to the patient packet you will need to have this for ENDO patients only.


Mylinks

  • Mylinks portal integration


Medical Records Release

  • Medical Records Release Form. Print out, complete and bring in to office.


Notice of Privacy Practices

  • Notice of Privacy Practices.


Patient Authorization for Disclosure of PHI

  • Patient Authorization to Disclose PHI to Family Member. Print out, complete and bring to office.


NPP Receipt and PHI Use

  • Notice of Privacy Practices Receipt and Protected Health Information Use and Disclosure Consent. Print out, sign and bring in to office.


Health Insurance Coverage Default

  • Health Insurance Coverage Default Policy. Print out, complete, sign and bring in to office.


Cape Fear Family Medical Care Endocrinology Patient Registration

  • Cape Fear Family Medical Care Endocrinology Patient Registration


CFFMC Policy Acceptance Form

  • Policy Acceptance Form for Cape Fear Family Medical Care. Print out, complete and bring to appointment.


Cape Fear Family Medical Care Endocrinology Policy Acceptance Form

  • Policy Acceptance Form for Cape Fear Family Medical Care Endocrinology. Print out, complete and bring to appointment.
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