Donate

Flagler Free Clinic

Forms and Documents

Administrative Forms

A01. A1C Cartridge Tracking Log
A02. Absence Notification
A03. FFC Accident Injury Form
A04. FAX Coversheet
A10. Federal Poverty Guidelines
A11. FFC Financial App Checklist
A20. FFC Financial Doc Req 202012
A22. FFC Financial Hardship Letter
A30. Front Desk Referral
A32. General Referral
A34. Impower Authorization
A35. Impower Mental Health Referral
A38. Navigators
A40. Patient Messages
A42. Patient Pickup Form
A44. Patient Request Form
A45. Patient Satisfaction Questionnaire
A46. Patient Satisfaction Survey Policy
A50. Phone Notes Form
A52. Preop Clearance Letter
A54. Prescription Review Form
A56. Referral To Human Services
A60. Volunteer Sign In Sheet

Clinical Forms

C01. Adverse Childhood Experience Questionnaire
C02. Consent For Steroid
C03. Covid-19 Consent Form
C04. Covid-19 Questionnaire
C05. Diabetes Podiatrist Flyer
C06. Diabetes Pump Log
C08. Influenza Vaccine Consent 2017-18
C09. Ophthalmology Clinic Evaluations
C12. Rules For Diabetes
C14. Suicide Risk Assessment
C16. TB Skin Testing
C18. Tomoka Eye Form

New Patient HIPPA Forms

N00. New Patient Packet
N01. Page 01-2 Patient Questionnaire
N00. New Patient Full Packet
N03. Page 03-6 Notice of Privacy Practices
N07. Page 07 Receipt of Privacy Practices
N08. Page 08 Release of Protected Health Info
N09. Page 09 Advent Medical Records Release
N10. Page 10 Bill Of Rights and Responsibilities
N20. Page 11 DH1032E

Diabetes Self Mgmt Forms

D01. DSME Referral Acknowledgement
D03. Diabetes Guidelines For Care
D05. Diabetes Podiatrist Flyer
D06. Diabetes Pump Log sheet
D08. Glucose Supply Log

Volunteer Training Forms

T01. DH1032 Instructions
T02. DH1032E Instructions
T04. Financial Support Form
T12. Post Volunteer Training Survey
T20. Sovereign Immunity Application Form
T24. Training Checklist For Front Office
T30. Volunteer Interest Form