Patient Resources

Patient Forms

Acknowledgement of Bill of Rights

Acknowledgment Receipt Form

Behavioral Health Release of Information

Behavioral Health Release of Information Form

Behavioral Health Release of Information- Spanish

Behavioral Health Release of Information Form

Mobile School-Based Health Center Enrollment

Mobile School-Based Health Center Forms

New Patient- Adult

New Adult Patient Form

New Patient- Adult, Spanish

New Adult Patient Form, Spanish

New Patient- Child

New Child Patient Form

New Patient- Child, Spanish

New Child Patient Form, Spanish

Notice of Privacy Practice

Notice of Privacy Practices

Patient Bill of Rights and Responsibilities

Patient Bill of Rights

Release of Information- Bloomingdale

Authorization to release medical information form

Release of Information- Cayuga

Authorization to release medical information form

Release of Information- Clinton

Authorization to release medical information form

Release of Information- Crawfordsville

Authorization to release medical information form

Release of Information- North Terre Haute

Authorization to release medical information form

Release of Information- Rockville

Authorization to release medical information form

Release of Information- South Terre Haute

Authorization to release medical information form

Release of Information- West Terre Haute

Authorization to release medical information form

Sliding Fee Scale- English

Sliding Fee Scale- Spanish

Sliding Fee Scale- Vietnamese

Student ISHAA Physical

New Sports Physical Form

Telemedicine

Telemedicine Consent Form

New Patient- Adult

New Adult Patient Form

New Patient- Adult, Spanish

New Adult Patient Form, Spanish

New Patient- Child

New Child Patient Form

New Patient- Child, Spanish

New Child Patient Form, Spanish

Acknowledgement of Bill of Rights

Acknowledgment Receipt Form

Notice of Privacy Practice

Notice of Privacy Practices

Patient Bill of Rights and Responsibilities

Patient Bill of Rights

Behavioral Health Release of Information

Behavioral Health Release of Information Form

Behavioral Health Release of Information- Spanish

Behavioral Health Release of Information Form

Release of Information- Bloomingdale

Authorization to release medical information form

Release of Information- Cayuga

Authorization to release medical information form

Release of Information- Clinton

Authorization to release medical information form

Release of Information- Crawfordsville

Authorization to release medical information form

Release of Information- North Terre Haute

Authorization to release medical information form

Release of Information- Rockville

Authorization to release medical information form

Release of Information- South Terre Haute

Authorization to release medical information form

Release of Information- West Terre Haute

Authorization to release medical information form

Telemedicine

Telemedicine Consent Form

Sliding Fee Scale- English

Sliding Fee Scale- Spanish

Sliding Fee Scale- Vietnamese

Mobile School-Based Health Center Enrollment

Mobile School-Based Health Center Forms

Student ISHAA Physical

New Sports Physical Form

Still have questions?

Give us a call at 1-844-900-WELL or fill out our contact form with your question and someone from our team will be in touch.