Call Us: (859) 626-7794 PAY ONLINE Madison Family Clinic Home About Us Contact Patient Forms Helpful Advice PATIENT FORMS Patient Portal We know how annoying it can be to visit the doctor’s office and fill out the required forms. Here you will find the forms where you can download, print and fill out at home. New Patient Adults Agreement of Financial Responsibility Consent to Care Health History Lifetime Beneficiary Claim Authorization Medical Visit Authorizations Medicare MSP Inquiry Notice of Privacy Practices Patient Rights & Responsibilities Notice of Privacy Practices Acknowledgement & Consent Registration & Health Assessment Authorization for Release of Information New Patient Pediatrics Agreement of Financial Responsibility Consent to Care Health History Medical Visit Authorizations Notice of Privacy Practices Patient Rights & Responsibilities Notice of Privacy Practices Acknowledgement & Consent Registration & Health Assessment Authorization for Release of Information General Patient Satisfaction Survey © 2019 All rights reserved Madison Family Clinic Website Designed by Dedicated Web Design, Berea KY

Call Us: (859) 626-7794 PAY ONLINE Madison Family Clinic Home About Us Contact Patient Forms Helpful Advice PROVIDERS Dedicated to Your Well-Being Clarice Dicks, P.A.-C Clarice is a graduate of the University of Kentucky College of Allied Health. This provider is certified through the National Commission on Certification Physician Assistants and licensed with the Kentucky Board of Medical Licensure. Clarice has been a practicing P.A.-C for over 20 years. Kim Sowden, A.P.R.N Kim is a graduate of Old Dominion University where she received her Bachelor of Science in Nursing. Kim received her Master of Science in nursing, Family Nurse Practitioner from Indiana State University. Kim is certified through the American Academy of Nurse Practitioners and has been a practicing nurse practitioner for over 20 years. Jennifer Maupin, PPCNP-BC Jennifer, a native of Richmond Kentucky, is a graduate of Eastern Kentucky University. There she received her Bachelor of Science in Nursing. After graduation she began work at University of Kentucky’s Children Hospital, Pediatric Intensive Care Unit. She received her Master of Science in Nursing in Pediatric Primary Care Nurse Practitioner at Cincinnati Children’s Hospital. She is nationally certified through the American Nurses credentialing center Kristin Morgan, APRN Kristin comes to us after 15 years’ experience (12 years as an RN and 3 years as a Nurse Practitioner). Kristin is energetic and dedicated to patient care with a well-rounded background in adult and pediatric health care. Focused on providing compassionate care and management of your health care issues for all age groups. Kristin completed her Bachelor’s Degree in Nursing at Eastern Kentucky University and received her Masters Degree in Family Nurse Practitioner, Advanced Registered Nurse at Walden University. © 2019 All rights reserved Madison Family Clinic Website Designed by Dedicated Web Design, Berea KY