Appointments
Pay My Bill
Patient Portal
  • About Us
    • Our Mission
    • Our Providers
    • Practice News
  • Services
    • Annual Wellness Visits
    • Annual Medicare Wellness Visit
    • Physical Exams: 18-65 Yrs.
    • Sick Visits
    • Immunizations
    • Other Services
    • Hospitals
  • Office Info
    • New Patients
      • How To Become A New Patient
      • New Patient Checklist
    • Appointments
    • Forms
    • Insurance & Billing
    • Policies
    • After Hours
  • Resources
    • Helpful Links
    • FAQs
    • COVID Assessment
  • Location
Contact
Long Logo

Ambler Primary Care

Lower Gwynedd 215-664-5799
Long Logo

Ambler Primary Care

Appointments
Patient Portal
Pay My Bill
  • About Us
    • Our Mission
    • Our Providers
    • Practice News
  • Services
    • Annual Wellness Visits
    • Annual Medicare Wellness Visit
    • Physical Exams: 18-65 Yrs.
    • Sick Visits
    • Immunizations
    • Other Services
    • Hospitals
  • Office Info
    • New Patients
      • How To Become A New Patient
      • New Patient Checklist
    • Appointments
    • Forms
    • Insurance & Billing
    • Policies
    • After Hours
  • Resources
    • Helpful Links
    • FAQs
    • COVID Assessment
  • Location

Forms

All Your Patient Forms In One Place

The following forms are here so that you can download and fill out prior to your visit.

Annual Patient Packet Forms

Adult Patient Registration (PDF)
Annual Consent and Acknowledgement (PDF)
Notice of Privacy Practices (PDF)
Adult Patient Registration (PDF)
Annual Consent and Acknowledgement (PDF)
Notice of Privacy Practices (PDF)
Authorization for Use & Disclosure of Protected Health Information (PHI) (PDF)
(Medical Records Release)
Health Information Exchange (HIE): FAQs (PDF)
Informed Consent: In-Office Procedures (PDF)
Patient Financial Responsibility (PDF)
Patient Portal Proxy Authorization (Age 18+)
Patient Portal: FAQs (PDF)
Patient Portal: Flyer (PDF)
Practice & Payment Philosophy (PDF)
Professional/Provider: Out-of-Network Disclosure Notification (PDF)

Patient Forms

Authorization for Use & Disclosure of Protected Health Information (PHI) (PDF)
Health Information Exchange (HIE): FAQs (PDF)
Informed Consent: In-Office Procedures (PDF)
Patient Financial Responsibility (PDF)
Patient Portal Proxy Authorization (Age 18+)
Patient Portal: FAQs (PDF)
Patient Portal: Flyer (PDF)
Practice & Payment Philosophy (PDF)
Professional/Provider: Out-of-Network Disclosure Notification (PDF)

Required Forms

Advocare Non-Discrimination Notice (PDF)
Advocare Payer List (PDF)
Explanation of Individual's Right to Appeal Health Insurance Determinations (PDF)
(New Jersey Only)
Grievance Procedure (PDF)

Quick Links

Patient Forms

Appointments

Insurance & Billing

COVID Info

Helpful Links

Contact Us

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