Patient Forms

Dear Patient,
For your convenience we have provided online access to new patient registration forms, authorization documents, health history forms, and privacy practice notifications. These documents may be downloaded or printed as needed. If you have any questions regarding your paperwork, please call your physician’s office.

Patient Registration Form    Authorizations Signature Page    Health History Form    Patient Privacy Notification Form

Application for Sliding Fee Discount Form    Financial Assistance for Rural Health    Request Medical Records    Submit Disability/FMLA Form

Thank you,
Provider Based Clinics,

Departments of Jennie Stuart Medical Center, Inc.