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 (to transfer records)
• 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/