Pay Now

Patient Portal Login

Forms

Patient Forms

Download commonly used patient forms before your appointment. We’ve organized general forms and office-specific release forms to make it easier to find what you need.

Most Common Forms

Looking for something quickly? These are some of the forms patients use most often.

Sliding Fee Application

Apply for discounted care based on income eligibility.

Download Form

Medical Records Release

Choose your office location to access the correct medical records release form.

View by Location

Health History

Complete this form prior to pediatric visits when requested.

Download Form

Patient Complaint Form

Use this form to share a concern or complaint with our team.

Download Form

General Forms

These forms are commonly used across ConnextCare services and locations.

Advance Directives

Information and forms related to advance care planning.

Download Form

Health History

Health history form for pediatric patient visits.

Download Form

Notice of Privacy Practices

Details about how your health information may be used and shared.

Download Form

Patient’s Bill of Rights

Important information about your rights as a patient.

Download Form

Adolescent Confidentiality Consent Form

Consent form related to adolescent confidentiality and care.

Download Form

School Based Health Center Enrollment Forms

Enrollment forms for ConnextCare School-Based Health Center services.

View Forms

Sliding Fee Application

Application for patients who may qualify for discounted fees.

Download Form

Patient Responsibilities

Review expectations and responsibilities related to your care.

Download Form

Instructions for Completing the Authorization for Release of Health Information

Step-by-step instructions to help you complete the release form correctly.

Download Instructions

Patient Complaint Form

Use this form to share a concern or complaint with our team.

Download Form

Designated Representative Pediatric

Authorize a designated representative for a pediatric patient.

Download Form

Designated Representative Adult

Authorize a designated representative for an adult patient.

Download Form

Office-Specific Release Forms

Choose your ConnextCare location below to access the correct authorization for release or request of medical information.

Central Square

Authorization for Release/Request of Medical Information

Fulton

Mexico

Medical Information Release Form

Oswego

Phoenix

Medical Information Release Form

Pulaski

Need Help Finding the Right Form?

If you are unsure which form you need, please contact us before your visit and our team will be happy to help.

QUICK LINKS

LOCATIONS & SERVICES

Substance Use Disorder Services

This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health related claims, including malpractice claims, for itself and its covered individuals.
In accordance with Federal law and U.S Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, age, disability, religion, sex, and familiar status. (Not all prohibited bases apply to all programs).
To file a complaint of discrimination, write UDSA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD).

Design by FunctionOne.com

Forms

Patient Forms

Most Common Forms

Sliding Fee Application

Medical Records Release

Health History

Patient Complaint Form

General Forms

Advance Directives

Health History

Notice of Privacy Practices

Patient’s Bill of Rights

Adolescent Confidentiality Consent Form

School Based Health Center Enrollment Forms

Sliding Fee Application

Patient Responsibilities

Instructions for Completing the Authorization for Release of Health Information

Patient Complaint Form

Designated Representative Pediatric

Designated Representative Adult

Office-Specific Release Forms

Central Square

Fulton

Mexico

Oswego

Phoenix

Pulaski

Need Help Finding the Right Form?

New digital billing statements are here