and

Burgaw Medical Center- (910) 259-3377


Hampstead Family Medicine- (910) 803-0340

Give us a call

Burgaw Medical Center​  


Our pricing Chart for visits will be available soon. Thank you for your patience. We look forward to meeting you! 


~Sincerely, The Hampstead/Burgaw Staff~

 Additional Payments and Fees
***These fees are not covered by insurance.***

All fees are non-negotiable and were created and implemented to compensate the Providers and employees for office hours utilized to process, fill-out, file, and fax requested Documentation.

These fees are the responsibility of the patient, facility or provider that has requested them.

The following fees apply to medical records and all and any forms that requires a provider or staff to fill out or sign outside of an apt. (i.e. FMLA, Jury duty letters, Disability letters, etc.)

 

Number                                Cost

0-5 pages                                   $5.00


5-10 pages                                 $10.00


11-25 pages                               $15.00


26-100 pages                             $25.00


Over 100 pages                         $55.00


All Medical Records

and Documentation                 $75.00 

New Patient Form: This form has you personal information and health history as well as family history. It must be filled out prior to your visit. 



HIPAA Form: This form is your Acknowledgement of HIPAA rights and responsibilities. Please List only family member you wish to have access and obtain your health care information. 


Office Policy Agreement: This form outlines the rules, guidelines and expectations of our facilities. This form requires a signature of your acknowledgement of these rules and guidelines and how they pertain to you as a patient.


​Notice of Privacy Practice: This form is to inform you that all information obtained by our facility for each and every patient is confidential. This requires a signature of acknowledgement 

 





New Patient Forms and Information

Payment Information 

The forms below are the required documents to establish care at our facilities. Each office may require additional forms to be filled out at your appointment, at the providers discretion 

Hampstead Family Medicine