Patient Notices

Notice of Privacy Practices

Privacy Practices

Medical Records Request Form

Authorization to Release Protected Health Information

If you do not have insurance or are not using insurance for your visit with us, you have the right to receive a Good Faith Estimate of the total cost of your bill. Our Patient Discount /Sliding Fee Scale Program offers reduced fees, same day discounts for medical care, and a fixed cap for mental health services. If you would like a Good Faith Estimate of your bill, please ask us when you schedule a service. If you receive a bill that is $400 or more than your Good Faith Estimate, you can dispute your bill.

Same-Day Discount - Medical

Same-Day Discount - Dental

For questions about Good Faith Estimates, visit No Surprises Act | CMS

Family Circle of Care provides equal employment opportunities without regard to a person’s race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), national origin, disability status, genetics or any other characteristic protected by law.

Notice of Privacy Practices

Medical Records Request Form

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