New
Patient Forms
Records
Release Form to Yelm Family Medicine
Use this form to give your previous provider permission to send
copies of your medical records to Yelm Family Medicine, PLLC.
Health History
Form
Please complete this form and bring it to your appointment if
you are new to the clinic, have had a change in your health or
it has been 3 years since it was previously completed. The information
provided on this form can be a valuable tool for providing quality
health care.
Financial
Policy
This form explains our financial policy and list the insurance
companies we are contracted to bill. Please bring this signed
form with you to your appointment.
Patient
Information Form
Please complete this form if you are new to the clinic or have
a change of address, phone number(s), marital status, insurance
or other information. We will enter some of this information
into our billing system and will also keep this form in your
medical record.
Privacy
Statement - Notice of Privacy Practice
This describes our policies and procedures and your rights regarding
your private information.
Notice of Privacy Practices Acknowledgement
Please sign this form to acknowledge you have been provided a
copy of our Privacy Statement.
Miscellaneous Forms
Records
Release Form from Yelm Family Medicine
Use this form to have your medical records from Yelm Family
Medicine, PLLC sent to your new provider's office. If you want
them sent to you, there will be a fee. Our copy service will
provide you information regarding the amount.
Accident Information
Complete this form for visit involving a injury. This form will
help identify who is responsible for payment when a office visit
or procedure is performed due to a injury. Many times your primary
insurance will not pay the claim when they believe another party
is responsible for payment. A couple of examples are; Work related
injuries and Motor Vehicle Accidents.
Application
for Employment
