PLATTE VALLEY MEDICAL CLINIC, P.C.   Caring For The Whole Family Right Here At Home!

Forms For A Clinic Visit:  (Please print, read, fill-out, sign, and bring to your appointment)

• • 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/