New Patient Forms (English)
Please review the new patient packet information–through the .pdf links below–print and fill in the information, and bring them with you to Archer Family Health Care at your first appointment.
New Patient Forms (Spanish) [Formulario de Paciente Nuevo]
Notice: Informing Individuals About Nondiscrimination and Accessibility
Discrimination is Against the Law
Archer Family Health Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex (consistent with the scope of sex discrimination described at 45 CFR § 92.101(a)(2)) (or sex, including sex characteristics, including intersex traits; pregnancy or related conditions; sexual orientation; gender identity, and sex stereotypes).1] Archer Family Health Care does not exclude people or treat them less favorably because of race, color, national origin, age, disability, or sex.
Archer Family Health Care:
- Provides people with disabilities reasonable modifications and free appropriate auxiliary aids and services to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats).
- Provides free language assistance services to people whose primary language is not English, which may include:
- Qualified interpreters
- Information written in other languages.
If you need reasonable modifications, appropriate auxiliary aids and services, or language assistance services, contact the Practice Manager.
If you believe that Archer Family Health Care has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: the Practice Manager for Archer Family Health Care located at 16939 SW 134th Avenue, Archer, Florida 32618 (P) 352-265-2550. You can file a grievance in person or by mail. If you need help filing a grievance, The Practice Manager at Archer Family Health Care is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
This notice is available at Archer Family Health Care’s website: UF Health Archer Family Health Care – UF Health.