Here you will find all the necessary patient forms. Click on the title to view and print the forms. Some the documents are in PDF (Adobe Acrobat) format. If you do not have Adobe Acrobat Reader installed on your computer, you can download the free reader directly from Adobe web site. See download link below.
New Patients: Please fill out New Patient forms, print, and bring with you to your first appointment.
New Patient Forms
Health History Form
Please complete this form and bring it to your appointment if you are new to the clinic, have had a change in your health or it has been 3 years since it was previously completed. The information provided on this form can be a valuable tool for providing quality health care.
Sports Physical Patient History Form
Please complete this form and bring it to your appointment when having a sports physical.
Financial Policy Aug 1st 2019
This form explains our financial policy and list the insurance companies we are contracted to bill. Please bring this signed form with you to your appointment.
Patient Information Sheet
Please complete this form if you are new to the clinic or have a change of address, phone number(s), marital status, insurance or other information. We will enter some of this information into our billing system and will also keep this form in your medical record.
Notice of Privacy Acknowledgement
Please sign this form to acknowledge you have been provided a copy of our Privacy Statement.
Insurance Disclaimer Aug 1st 2019
All new patients please read and sign this form regarding an exception to our insurance acceptance policy.
Records Release TO
Use this form to have your medical records from Yelm Family Medicine, PLLC sent to your new provider’s office. If you want them sent to you, there will be a fee. Our copy service will provide you information regarding the amount.
Records Release FROM
Use this form to give your previous provider permission to send copies of your medical records to Yelm Family Medicine, PLLC.
Privacy Statement – Notice of Privacy Practice
This describes our policies and procedures and your rights regarding your private information.
Complete this form for visit involving a injury. This form will help identify who is responsible for payment when a office visit or procedure is performed due to a injury. Many times your primary insurance will not pay the claim when they believe another party is responsible for payment. A couple of examples are; Work related injuries and Motor Vehicle Accidents.
|Download Adobe Acrobat Reader
Free software for viewing and printing Adobe Portable Document Format (PDF) files. Adobe PDF files can be viewed on most major operating systems.