Family Physicians of O'Fallon
Medical Forms
The following forms relate to your privacy and medical records. They are provided here for your convenience, but are also available in our office. These forms are provided in both Adobe Acrobat format (.pdf) and Microsoft Word format (.doc).

If you are a new patient looking for the new patient paperwork to send in , please click here

Forms -- Adobe Acrobat Format:

Note: You must have Adobe Reader to open the following forms.
All forms will open in a new browser window.
  1. Authorization to Access your own Medical Record
  2. Authorization to Release Records to another facility or entity
  3. Authorization for Release of Medical Information (to family members or other individuals)
  4. Authorization to Revoke Prior Authorization
  5. Request to Amend Your Private Health Information
  6. Acknowledgment of Privacy Notification
  7. Insurance Change Form
  8. Illinois Healthcare Power of Attorney

Forms -- Microsoft Word Format:

All forms will open in a new browser window.
  1. Authorization to Access your own Medical Record
  2. Authorization to Release Records to another facility or entity
  3. Authorization for Release of Medical Information (to family members or other individuals)
  4. Authorization to Revoke Prior Authorization
  5. Request to Amend Your Private Health Information
  6. Acknowledgment of Privacy Notification
  7. Insurance Change Form
  8. Illinois Healthcare Power of Attorney
  9. Medication Refill Request

Sports and School Physicals

Note: These forms require the Adobe Reader to open, read, and print. They need to be filled out prior to your appointment.
  1. Sports Physical Form
  2. School Physical Form

Immunization Forms

Note: Before signing the Immunization Contraindication Checklist, please make sure that you have read the appropriate vaccine fact sheet (available here).

Forms are available in both pdf (Adobe Acrobat) and doc (Microsoft Word) formats.

  1. Immunization Contraindication Checklist -- Adobe Acrobat Format (.pdf file)
  2. Immunization Contraindication Checklist -- Microsoft Word Format (.doc file)