Forms

MEDICAL RELEASE FORM

To have medical records sent to us or to request your medical records, please fill out the Medical Release Form and fax to (321) 726-1610.

ELIGIBILITY AFFIDAVIT FORM

To receive medical services from L3HFMC, please fill out the Affidavit Form and fax to (321) 726-1610.

COUNSLOR NEW PATIENT FORM

For first-time patients of our Licensed Clinical Social Worker, please fill out the New Patient Form and fax to (321) 726-1610.

2021 FORMULARY

If you do not need a refill, but have a question or comment for the pharmacy, call (321) 726-1614 or email us at hfmcrx@mttcorp.com

PHARMACY REFILL FORM

NOTICE OF PRIVACY PRACTICES

The L3HFMC patient portal provides you with 24/7 access to your medical records, the ability to make an appointments online, send your provider a prescription refill request and other convenient tools to more effectively manage your health.

HIPAA Information

On April 14, 2003, the Health Information Portability and Accountability Act (HIPAA) went into effect for all U.S. medical facilities. HIPAA is designed to assure the confidentiality, integrity and security of patient health information. The L3Harris Family Medical Center (L3HFMC) is compliant with Florida’s privacy law and has implemented all necessary procedures to be in compliance with HIPAA. We will post our Notice of Privacy in all waiting rooms and on the L3HFMC website.

In order to continue to protect patient privacy we ask all patients to respect the privacy of other patients. This may include being asked to have a seat in the waiting area until we can accommodate you at the registration desk, pharmacy window and/or patient care area. Due to the nature of the conversations that could be overheard in the patient care area, any friend or family member that accompanies a patient must stay in the exam room with the patient. If the patient objects to having anyone in the exam room while the doctor examines them, they will be asked to stay in the waiting room.

We will also need to obtain your authorization to leave appointment confirmations on your work and/or home phone and/or to send an email that may contain protected health information. Communication release forms are linked below.

HIPAA requires healthcare providers to obtain written authorizations from the patient to release any protected health information that is not related to your treatment, payment, healthcare operations or required by law. For example, we will need to have a written authorization to release or fax immunization records to the public schools.

L3Harris Family Medical Center was established by L3Harris Technologies to provide high-quality, primary health care services.

Medical Technology Transfer Corporation based in Santa Monica, CA manages and operates L3HFMC and University Center Imaging. Operates in Melbourne, FL. 

L3Harris Family Medical Center is located at:

The Oaks Plaza
1800 West Hibiscus Boulevard,
Suite 101
Melbourne, Florida 32901

One block directly north of the Melbourne Square Mall

Clinic: (321) 726-1600
Pharmacy: (321) 726-1614
Wellness: (321) 409-4980