What is an AFFILIATION FORM?

To print a copy of the clinic Affiliation Form click HERE.

You MAY print, complete, and return your form to the clinic (we MUST have the original copy, we can not accept scanned/emailed copies). Alternately, you may come to the clinic in person at any time during business hours to complete your affiliation form.

One of the requirements of the Blended Capitation Model is to clearly identify who are patients of our clinic. This is done by having each patient sign an affiliation form. 

By signing this form you will be “attached” to Bear Street Family Physicians Clinic and agree to contact us first for your medical needs (before going to a walk-in clinic).  This also means that if you access primary care elsewhere (i.e. a walk-in clinic) we are notified, and this pulls funds and resources away from our facility, your Medical Home.

Every possible opportunity to provide care for you at Bear Street Clinic will be made available to ensure you can be seen as needed.   We recognize that urgent needs will arise and, as always, Emergency Room visits remain available to you. 

Thank you for choosing Bear Street Family Physicians to be your Medical Home. We look forward to continuing to provide exceptional care for you and your family.