Forms

We are currently accepting new patients.  If you are a new patient, or would like to become one, please have a look at the important documents below.  Filling these documents out in advance and being aware of our policies will make your first appointment faster and smoother and it will help make your overall experience that much better!

Patient Info/Financial Statement - For faster service during your first appointment, please print out this document, fill it out, and bring it with you to the office.

 

Prescription History Consent - This form gives us permission to speak with your pharmacy to obtain information on your prescription history.

 

Important Co-pay Information - This helps guide you through the co-pay process as it relates to your annual physical.

 

Pre-Visit Information Form - This form can be filled out and submitted in advance to let your provider know if you have any specific issues that you would like to address, informs them of any medications you are taking, and more.  This form can be mailed or faxed to our office ahead of time, or printed and brought with you to your visit.

 

Health Care Proxy Form - Please print this form, fill it out, and bring it with you to your first appointment.

 

Important Insurance Info - Please read this page to learn more about what insurance companies we work with and what your financial responsibilities may be for your visits.

 

MOLST (End Of Life Treatment) - Please print this document, fill it out, and bring it to any visit where end-of-life treatment will be discussed.

 

Office Policies - This document explains our office policies on cancellations, emergencies, prescriptions, referrals and more.

 

Privacy Policy - We take your privacy very seriously and this document details the process for sharing your information with other medical staff or medical specialists when necessary and explains how we keep your patient information safe and secure.

 

Patient Health Questionaire  - Your provider may ask you to fill out this simple questionaire and bring it with you to your visit.

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Medical Records Release   - This document allows past doctors or specialists to release your medical records to Mill City Medical.

 

Other Important Forms - Workers' Comp, Auto Accident