Patient Forms

We only serve patients residing in adult family homes and assisted living facilities. Please note that we do not provide services to patients in private homes or in clinic settings.

Important Information for New Patient Registrations

We are committed to providing focused and consistent care to our existing community. At this time, we are exclusively accepting new patient registrations from residents currently living in facilities that we already service. Please note that we are not accepting new facilities into our network at this current time. We appreciate your understanding as we maintain the quality of care for our current partners and patients..

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New Patient Enrollment Online (preferred)

If downloading registration packet, you may:

  • Fax completed forms to 855-619-1638

  • Email forms to faith-home-care@myupdox.com

    Due to the high volume of new patient registrations, processing may take 10–15 days. Thank you for your patience.

Download Registration Forms

Other documentation needed:

  • Copy of POA or guardianship if forms are signed by an individual other than the patient (Required)

  • Advance Directive or POLST form

  • Copy (front and back) of BOTH primary and secondary insurance cards

  • Copy of Driver’s License/Identification

  • Current medication list (Required)

  • Last provider records (if available)

Connect to Patient Portal

You can access your health records online by signing up.

(Will need to include mobile number and email)

Patient Portal