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Forms to fill out online

Not printable

we are currently not accepting new patients

Established Patient Paperwork (current patients)

Dr Leistikow NEW patient paperwork

For new patients, please fill out the Release of medical records for each office that you would like us to have records from us.  It must be complete with a fax number to send the request to. 

Forms to Download

Release of Records Request

Personal Medical History

Family Medical History

FMA Acknowledgement of Privacy

Financial Policy

Notice of Privacy Practices

Card on File

Common Fees (self pay)
New Patient Fee 
140.00 to 271.20 depending on level of service
Established Patient 
112.00 to 222.00 depending on level of service

* These fees are discounted rates when paid at time of service
**This is the fee for office visit only.  Any procedures, vacines, and test, etc are billed seperately

Click here to learn about Surprise Billing

ATTENTION:  NO SHOW OR SAME DAY CANCELS.  We understand emergencies happen, please notify us as soon as possible if you need to cancel.  No Show appointments are charged $100.00 each time.  Same day Cancels (less than 24 hours) are charged $75.00 to $100. 

Office Policies

Office Visit Policy

All patients are required to present a valid driver’s license or photo ID, a current medical insurance card, as well as any and all estimated patient responsibility at time of service. Patients without verifiable health insurance will be required to pay at time of service to be seen. 

We ask that patients check in 10-15 minutes before their appointment time. Patients who check-in 10 minutes after their appointment will be asked to reschedule.

We do understand there are times when you will be late due to circumstances you cannot control. In every case we will do what we can to accommodate you, however it is not always possible.

Same Day Cancelation and No Show Policy... Fee $75.00 to $100.00

Please be aware that we require 24 hours notice for cancellations. Each no show or same day cancellation will be assessed a no show fee for patients with commercial insurances or for self pay patients. Medicaid patients are not subject to a fee but non-compliance with this policy is cause for release. 

3 or more canceled/rescheduled or missed appointments may result in dismissal from the practice. We do understand there are times when 24-hour notice is not possible. Emergency cancellations or missed appointments will be evaluated on an individual basis.

Urgent Needs

We do not offer a traditional on call service for after hours concerns. However, if an urgent matter arises we provide an after hours nurse triage service. Please see our page on After Hours care under the Services menu for more information. 

Refill Policy

Most prescription refills require an appointment. Please bring a printed list of your medications and all supplements you are taking to your appointment. Please plan ahead for all appointments and refills as we require at least 24-48 hours notice for all refills. 

Insurance Claims/Billing

Family Medicine Associates accepts most major commercial insurance carriers as well as Medicaid and Medicare. As a courtesy to our patients, we will file insurance claims for those insurances with which we participate. Please remember, any allowed amount not covered by insurance is ultimately the patient’s responsibility. Please contact your insurance company if you have questions concerning your benefits and if Family Medicine Associates is an in network provider. 


Payment will be required at the time of service for all services that are non-covered or determined to be the patient’s responsibility, including co-payments. 

Pain Management and Controlled Substances

Our providers prescribe controlled substances in extremely limited and appropriate situations only. We will not take on any new pain management cases, we will be happy to manage the rest of your care but will refer to pain management clinics for pain medication prescriptions. 

Respect and Collaboration

We view healthcare as a collaborative relationship between patient, provider, and office staff. We care about our patients' well being and we expect our staff to treat every patient with the care and respect that they deserve. As such we expect our patients to return the gesture by treating our staff with respect. Any mistreatment or disrespectful behavior toward our staff will be passed on to management and is cause for immediate dismissal from our practice. 

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