Forms & Visit Information


In order to serve you better, please review our forms and visit information

FORMS

  • Consent to Treat a Minor
  • HIPAA Notice of Privacy Practices
  • Medical Records Release of Information
  • Patient Medical Record

VISIT INFORMATION

  • Existing Patients
  • New Patients
  • Insurance/Payment Information
  • Patient Information Packet
  • Travel Consults and Shots

Patient Forms for Download

All documents are the property of AALFA Family Clinic and may not be edited, amended, or reproduced without express permission of AALFA Family Clinic.

Patients under 18 must be accompanied by a parent or guardian. If a parent or guardian cannot be present, this consent form must be signed before the patient can be seen.

HIPAA Privacy Notice

We take your privacy very seriously. Our clinic is committed to complying with all HIPAA regulations, which are designed to safeguard your personal medical information. Please reference the HIPAA Privacy Notice, above, for detailed information on how we protect, use and disclose your personal health information.

HIPAA Receipt / Financial Responsibility Agreement

Patient Medication Record

Are you taking any medications (prescription or over-the-counter), vitamins, herbal supplements, etc.? If so, please fill out our Patient Medication Record and bring it to your next office visit.


Getting Ready for Your visit

In order to serve you better, please review our forms and visit information.

To help protect your identity, and ensure accurate medical chart documentation, at every visit you will be required to present a current Photo ID and current Insurance Card at the front desk.

You may be asked to update your Patient Profile and/or fill out various surveys for quality assurance purposes.

You may be asked to update your Patient Profile and/or fill out various surveys for quality assurance purposes.

Existing Patients

Please bring to your appointment​: * Photo ID * Insurance information and card(s) * A list of your current medications, including vitamins, supplements and over-the-counter medications (if changed from your last visit) * List of questions/concerns you wish to address with your Provider

New Patients

Please bring to your appointment: * Photo ID * Insurance information and card(s) * Your current medications, including vitamins, supplements and over-the-counter medications * Information about what treatment(s) and medication(s) have been tried in the past * Medical records from prior visits that you think may be helpful * List of questions/concerns you wish to address with your Provider

Insurance/Payment Information

While we do accept most major health insurance plans, we cannot guarantee your insurance will cover our services. It is the patient's responsibility to contact their member services prior to their visit to verify eligibility and benefits.

The patient accepts ultimate responsibility for payment, regardless of insurance coverage or payment problems. * Copays are due at the time of service. * We accept cash, checks, VISA, Discover, American Express and MasterCard.

Visit our Billing & Insurance page for more information.

Patient Information Packet

Our Patient Information Packet has been compiled as a resource to provide our patients current information about HIPAA Privacy regulations, our clinic policies regarding Medication Refills, Billing and Insurance, Protection Against Medical Identity Theft, and more about the care we provide at AALFA Family Clinic.

Please reference this packet for any questions you may have regarding the care you receive at AALFA Family Clinic.

Clinic Hours / Appointments

Monday-Friday: 8am-5pm
Appointments: 651-653-0062

Urgent Care / After-Hours Care

We offer same day appointments during regular clinic hours for Urgent Care.

After-hours our doctors are on-call through our answering service: 651-653-0062