Forms The following forms and corresponding instructions have been provided for your convenience. Please note that these forms may not be the appropriate forms for all patients in all circumstances. Please find the form you’ll need, download, fill out, and bring with you at your appointment so we can minimize the wait time at the office.

Family Medicine & Convenient Clinic FMCC Demographics FMCC Demographics – fill-in version FMCC Health Information FMCC Health Information – fill-in version Release and Assignment, Authorization for Release of Information and Financial Policy Release and Assignment, Authorization for Release of Information and Financial Policy – fill-in version FMCC Request for Release of Medical Information FMCC Request for Release of Medical Information – fill-in version Medicare Questionnaire

Midwest OB-GYN Clinic Midwest Ob/Gyn Demographics – Adults Midwest Ob/Gyn Demographics – Adults – fill-in version Midwest Ob/Gyn Demographics – 18 and under Midwest Ob/Gyn Demographics – 18 and under – fill-in version Midwest Ob/Gyn Health History Release and Assignment, Authorization for Release of Information and Financial Policy Release and Assignment, Authorization for Release of Information and Financial Policy – fill-in version Midwest Ob/Gyn Request for Release of Medical Information Midwest Ob/Gyn Request for Release of Medical Information – fill-in version Medicare Questionnaire

Formas en Español FMCC Demographic – Spanish FMCC Health Information – Spanish FMCC Release and Assignment – Spanish Midwest Ob-Gyn Demographics – Adult – Spanish Midwest Ob-Gyn Demographics – Adult – Spanish – fill-in version Midwest Ob-Gyn Demographics – 18 and Under – Spanish Midwest Ob-Gyn Release and Assignment – Spanish

HIPAA HIPAA Policy