Patient Forms


 

The following forms are available for download.  The forms on the right side of the page are also available on the Patient Portal! 

 

Click Here for the Advance Directives Pamphlet

An Advance Directive is a written document in which you specify what type of medical care you want in the future, or who you want to make decisions for you, should you lose the ability to make decisions for yourself. Three types are a Durable Power of Attorney for Health Care, a Living Will, and a Do-Not-Resuscitate Declaration. There is also a Declaration of Anatomical Gift, to take effect after your passing. 

 

Patient Registration Form

New patients, please fill this out and bring with you to your appointment. Current patients, please let us know if any information has changed. 

 

Health History Questionnaire

An online version of this form is available on the Patient Portal! This is our preferred method of completion, as it integrates directly into your patient chart and saves time as well as paper! Click here to log in! 

 

Patient Centered Medical Home Form

A Patient-Centered Medical Home is a partnership between the patient and his/her physicians. Please fill this out and bring with you to your initial or physical visits. 

 

Durable Power of Attorney Form

A Durable Power of Attorney for Health Care is a document in which you appoint another individual to make medical treatment and related personal care decisions for you. 

 

Notice of Privacy Practices & Patient Rights

This notice describes how medical information about you may be used and disclosed and how you may have access to this information. New patients, please review. 

 

Living Will Form

A Living Will is a written document in which you inform doctors, family members and others what type of medical care you wish to receive should you become terminally ill or permanently unconscious. 

 

HIPAA Acknowledgement

This form acknowledges that the patient, parent or legal guardian reviewed our Notice of Privacy Practices & Patient Rights form. RPC provides this form to comply with the Health Insurance Portability & Accountability Act of 1996. New patients, please review, sign and date this form. 

 

DNR - Including Doctor's Signature

DNR - Without Doctor's Signature

A Do-Not-Resuscitate (DNR) Declaration is a written document in which you express your wish that if your breathing and heartbeat cease, you do not want anyone to attempt to resuscitate you. 

 

Declaration of Anatomical Gift

A Declaration of Anatomical Gift is a statement declaring what organs or body parts, if any,  you wish to donate upon your death for medicinal purposes. 

 

Payment Policy Agreement

Our payment policy is a standard financial agreement for all patients that outlines what payments are due at the time of your visit. Please be sure to sign the form prior to your visit with us. 

 

Community Resource Directory

National and local resources for specific conditions or individuals.

 

 

*Advance Directives information retrieved from Michigan State Long Term Care Ombudsman Program

*HIPAA information retrieved from the U.S. Department of Health and Human Services

Location
Rochester Primary Care
1349 S. Rochester Rd., Suite 100
Rochester Hills, MI 48307
Phone: 248-759-5460
Office Hours

Get in touch

248-759-5460