New patients will have paperwork to complete and will be asked to bring a picture ID and proof of income.
If you have access to a printer, you can download, print and complete the paperwork in advance to save time and help you prepare for your visit. You will be able to complete the forms while you are at the clinic if you prefer.
Patient Demographic/Consent to Treatment/HIPAA Authorization/Release Form
This form gives Health Partners Free Clinic staff and volunteers some basic demographic information for your patient profile and permission to treat your medical conditions. Also included is the HIPAA section regarding your privacy. As your privacy is very important to us; our policy gives you the information on how and when, with your permission, we share your medical history or concerns with others. Please let the staff or volunteers know if you'd like to review these documents.
This form explains what you can expect from Health Partners Free Clinic and what we expect from you.
This form provides Health Partners medical staff with information about you and your health history.
Authorization for Release of Health Information
This form is for you if you've received medical care elsewhere so we can get your medical records.