Forms For A Clinic Visit: (Please print, read, fill-out, sign, and bring to your appointment)
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- Patient Information (For New Patients)
- Notice of Privacy Act (For New Patients)
- Health History Form (For New Patients, Annual Exams)
- Consent for Patient Contact (For New Patients)
- Medicare as Secondary Payer (For Medicare Patients Annually, New Medicare Patients)
- Financial Policy (For New Patients)
- Authorization to Use and Disclose Medical Records: ALL requests require payment due to postage and personnel time to retrieve records. Please be a responsible and considerate person and include payment of the fee of the $20. (to transfer records requires $20 check or credit card authorization; fee will be up to $20), Eliminating payment will delay records retrieval and subject patient to being sent to.
- Health Risk Assessment for Medicare Exam (For Medicare Patients for Annual Exam)
- High School Physical Form (Download and sign front and back)
PVMC / Medicare / National Health Service Corps Policies For You to Peruse:
- Day of Service Payment Discount
- Late Policy
- No-Show Policy
- Sliding Scale / Federal Poverty Level 2016
- Sliding Scale Application (download and sign for sliding scale)
- Patient Statement on Financial Status (download and sign for sliding scale)
Patient Information Sites (that we feel are trustworthy):
- Family Doctor Patient Website: http://familydoctor.org/online/famdocen/home.html
- UpToDate: http://www.uptodate.com/patients/index.html
- Mayo Clinic: http://www.mayoclinic.com/health-information/
- Wyoming Telehealth: http://www.uwyo.edu/wind/wytn/
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