Resources: Patient Forms

IHA Medical Group is now offering a number of the most-commonly requested patient forms in an electronic version. You will find several forms below which may be completed prior to your next appointment. They may be completed by hand or electronically after saving a copy to your desktop. This will allow our patients plenty of time to complete all necessary paperwork prior to arriving at the office. If you have any questions about which forms you should fill out, please contact your office directly.

Internal Medicine Forms

Family Medicine Forms

Adult History New Patient Form
- Fill out this form if you are a new patient to our office and bring to your first appointment
Adult Immunizations
Authorization for Release of Information
- This form is used to request that a health care provider (physician, practice, hospital, etc.) to release your medical records, either to the patient, a third party (such as an employer or insurance company), or both.
Authorization for Sharing Information
- This form allows your protected health information to be shared with a person that you choose. This includes or excludes special consent information (HIV (Human Immunodeficiency Virus) related illness, testing OR Sexually Transmitted Diseases; AIDS (Acquired Immunodeficiency Syndrome) or ARC (AIDS Related Complex); Information about Alcohol and Drug Abuse Treatment; Information about Mental Health Services and Social Services. In addition, other private information such as pregnancy or contraceptive management information can be shared.
Authorization to Treat Minor
Financial Assistance Application
Medicare Wellness Checkup Risk Assessment (HRA)
- Fill out this form if you have an upcoming appointment for a Welcome to Medicare or Medicare Wellness Visit
Physical Evaluation Form (MHSAA)

ADHD Vanderbilt Assessment Form: Parent
ADHD Vanderbilt Assessment Form: Teacher
Adult History New Patient Form
- Fill out this form if you are a new patient to our office and bring to your first appointment
Adult Immunizations
Authorization for Release of Information
Authorization for Sharing Information
Authorization to Treat Minor
Financial Assistance Application
Medicare Wellness Checkup Risk Assessment (HRA)
- Fill out this form if you have an upcoming appointment for a Welcome to Medicare or Medicare Wellness Visit

Pediatric Forms	Obstetrics & Gynecology Forms
ADHD Vanderbilt Assessment Form: Parent ADHD Vanderbilt Assessment Form: Teacher Authorization for Release of Information Authorization for Sharing Information Authorization to Treat Minor Health History Physical Evaluation Form (MHSAA) Screening Questionnaire for Immunizations	Adult Immunizations Authorization for Release of Information Authorization for Sharing Information Authorization to Treat Minor Behavioral Health Standard Consent Form Financial Assistance Application OB/GYN History Form Social Worker Financial Responsibility Waiver

Video Appointment and Telephone Appointment Forms	Spanish Forms
HIPAA Form Master Consent Form No Show Policy and the Acknowledgement of Financial Responsibility	Autorización para Compartir información Pediatría Autorización de tratamiento para menores Reconocimiento de responsabilidad económica

Resources: Patient Forms

Internal Medicine Forms

Family Medicine Forms

Pediatric Forms

Obstetrics & Gynecology Forms

Video Appointment and Telephone Appointment Forms

Spanish Forms