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
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Family Medicine Forms
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- 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
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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.
- 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)
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Pediatric Forms
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Obstetrics & Gynecology Forms
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Video Appointment and Telephone Appointment Forms
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Spanish Forms
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