Patient Forms
New Patients
In order to establish care at SCHD, new patients are required to complete the Patient Intake Form and the Financial Policy, as well as read the HIPAA Notice of Privacy Practices and then sign the HIPAA Signature Form. These forms must be filled out in entirety to ensure you receive the best possible care. Please arrive 15 minutes prior to your appointment time to complete the necessary paperwork. To save time on check-in, you may print and sign these forms and bring to your appointment.
School Physicals
Parents/Guardians are to complete the School Physical Examination Medical Record form and sign it prior to arrival. Please make sure the student brings the signed form to their appointment.
HIPAA / Medical Records Release
The Health Information Portability & Accountability Act requires that we do not share the health information of any of our patients to third party entities without written permission. This means that we cannot fax forms, speak to counselors or mail documents unless you complete, sign and list the organizations that you give us permission to share information with on our Authorization for Disclosure of Health Information form. HIPAA also restricts us from speaking with the parents of patients over 18 years of age unless the patient has completed and signed the following form authorizing us to do so:
Authorization for Disclosure of Health Information Pinedale Clinic
Authorization for Disclosure of Health Information Marbleton Clinic
Insurance
Insurance carriers require updated paperwork. We encourage you to arrive 15 minutes early so that we may update our records. You need to bring your correct insurance card and photo identification with you for every visit. We accept many insurance plans. Please check with your insurance provider directly to determine if SCRHCD physicians are listed as participating providers with your particular insurance plan. The health insurance policy is a contract between the policyholder and the insurer. Health insurance does not relieve the patient and/or family of financial responsibility for services received.
Form for personal representative authorization
If for any reason someone other than a parent or legal guardian needs to bring a child in for an appointment, it is important that you complete the Personal Representative Authorization Form. This form permits us to release personal information to the designated representative.
Advanced Directives
An advance directive is a general term that refers to your verbal and written instructions about your future medical care, in the event that you are unable to speak for yourself. You have the right to give instructions about your own healthcare. You also have the right to name someone else to make healthcare decisions for you. The Advance Healthcare Directive form lets you do either or both of these things. The form can be found here: Advanced Directives - My Choice Booklet
For your information, on page 7 of the Advanced Directive form, there is additional information on the POLST (Providers Orders for Life Sustaining Treatment) form, which is used to implement a DNR (Do Not Resuscitate) order, if this is something you are interested in. This is an individual choice that should be discussed with your healthcare provider before it can be implemented. The link for this form is provided for your reference below:
https://health.wyo.gov/wp-content/uploads/2016/04/187-18432_WyoPOLSTFormFINAL.pdf