PATIENT FORMS

At EOPCC we value your time. To lessen time spent on registration, please complete and print the following forms and present them to one of our medical secretaries at the time you check-in.

As of August 1, 2009, EOPCC is in compliance with the Federal Trade Commisions Red Flag Rules. Please bring a photo id with you to your appointment. Read our Identity Theft Protect policy by clicking here.

(If you cannot access the forms, click here to download the software needed to access them.)

Assignment of Benefits

Financial Policy

HIPAA Acknowledgment

HIPAA Notice of Privacy Practices

Medical History

Patient Detail Sheet

MISCELLANEOUS FORMS

Advance Directive - Maryland

Auto Accident Claim Information

Authorization for Medical Treatment of Minors

Durable Power of Attorney

Financial Hardship Application

Medical Records Release

Workers Compensation Claim Information

121-123 W. Main Street • P.O. Box 1219 • Emmitsburg, MD 21727 • Phone: (301) 447-3310 • Fax: (301) 447-5851 • Email: info@eopcc.com
Hours: Mon and Wed 8:30 - 4:00 • Tues and Thurs 8:30 - 8:00 • Friday 8:30 - 5:00