Information for Clinical Staff

Clinic Forms and Documents:

• Intake and Health History Form

• Visit Notes

• Wellness Flow Sheet (optional)

• Medical Financial Assistance Program Clinician Checklist

• Medical Financial Assistance Program Waiver

• Medical Financial Assistance Program Intake Form

Reports:

• Clinic Report Form

• Worksheet for In-kind Distributions (optional)

Releases:

• Annual Release and Confidentiality Form

• Photo and Video Release Form

Referrals:

• Referral Form

• Referral Reminders for Immediate Concerns