Wintergreen Medical Center
324-A Beacon Drive
Winterville, NC 28590
To call for an appointment use the office number above, leave a message, and your call will be
If you have Medicare insurance, please go here for more information before scheduling an
Before Your First Appointment:
We need to know several things about you:
1. Your prior medical history
2. All your demographic information including insurance policy numbers and group numbers, etc.
3. A "Release of Medical Information" form for you to provide to your previous providers of medical care so
we may receive your prior medical records. We ask that you request the last two years of progress notes,
and all xrays and labs, and any surgery/operative or procedure reports.
4. Also there are (federally mandated) HIPAA privacy forms to read, print, sign, and return.
All of this you can download here in a packet of materials, or download ALL of the following individual
1. Medical History Form - print, fill out, and bring to your initial visit.
2. Demographic and Insurance Information Forms - print, fill out, and return at your initial visit.
3. Release of Medical Records Form - print, fill out, and fax/mail/give to your current medical provider(s) so
they may release records to us. Or, bring to your initial visit and we will send it to your previous provider.
Policy, print and sign all portions and bring all these forms in with you at your initial visit.
Calvin Ellis, PA-C
Carol Gates DNP, FNP-BC