Forms - MCHC Health Centers In Mendocino County

Forms - MCHC Health Centers In Mendocino County
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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.
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
and return to Patient Financial Services.
También está en español
If you are a new sliding scale patient, please review the
Income Documentation 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
.
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Patient Rights and Responsibility
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(707) 468-1010
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: UKIAH, WILLITS AND LAKEPORT
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