Forms

Many forms are necessary for us to provide you with the health services you want. It is important that all forms in your file are accurate and up to date so that we can give you the care you need when you need it.

New Patient Registration

If you are a new patient, please fill out the Patient Registration  form and bring it with you to your appointment. También está en español.

Release of Health Information

Please complete the Authorization for Release of Health Information if you would like us to transfer your previous or current medical records to another doctor. También está en español.

Patient Feedback

If you would like to share a concern about any aspect of your care at MCHC, please download and complete the Patient Feedback Form; then either bring it with you to your next visit or mail it to the address shown. También está en español.

Financial Assistance 

If you would like us to help you apply for health insurance or for sliding scale  to help pay for your health care bills, please fill out the Patient Financial Screening Form and return to Patient Financial Services. También está en español.

If you are a new sliding scale patient, please review the Documentation of Income Form to learn how to prove your income. También está en español.

Privacy Practices

We provide all new patients with a Notice of Privacy Practices when they register, and to returning patients if the notice has changed since their last visit. Click here to download this document in english. Chasque aquí para descargar la VERSIÓN DE LA ESPAÑOL de este documento.