Thank you for visiting our website. Here you will find forms that you will need to complete before your first visit at our family medical practice in Carolina Beach, Chapel Hill, Clinton, Dillon (SC), Jacksonville, Emerald Isle, Kenansville, New Bern, Mt. Airy, Richlands, Sneads Ferry, Southport, Swansboro or other NC locations. Please download the following pdf forms and fill them out in advance of your first visit. You can also schedule your appointment with our family practice doctor in NC online by clicking the schedule and appointment tab below. These forms are not required before a visit to our urgent care services.
Patient Bill of Rights
Good healthcare delivery depends upon the cooperative relationship between you and your physician, as well as between you and the Clinic.
I. Information Disclosure
You have the right to receive accurate and easily understood information about your health plan, healthcare professionals, and healthcare facilities. If you speak another language, have a physical or mental disability, or just don’t understand something, assistance will be provided so you can make informed healthcare decisions.
II. Choice of Providers and Plans
You have the right to a choice of healthcare providers that is sufficient to provide you with access to appropriate high-quality healthcare.
III. Access to Emergency Services
If you have severe pain, an injury, or sudden illness that convinces you that your health is in serious jeopardy, you have the right to receive screening and stabilization emergency services whenever and wherever needed, without prior authorization or financial penalty.
IV. Participation in Treatment Decisions
You have the right to know all your treatment options and to participate in decisions about your care. Parents, guardians, family members, or other individuals that you designate can represent you if you cannot make your own decisions.
V. Respect and Nondiscrimination
You have a right to considerate, respectful and nondiscriminatory care from your doctors, health plan representatives, and other healthcare providers.
VI. Confidentiality of Health Information
You have the right to talk in confidence with healthcare providers and to have your healthcare information protected. You also have the right to review and copy your own medical record and request that your physician amend your record if it is not accurate, relevant, or complete.
VII. Complaints and Appeals
You have the right to a fair, fast, and objective review of any compliant you have against your health plan, doctors, hospitals or other healthcare personnel. This includes complaints about waiting times, operating hours, the conduct of healthcare personnel, and the adequacy of healthcare facilities.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.
Contact Office: Med First Privacy Officer
Address: 308 Dolphin Drive, Jacksonville, NC 28546