Patient Forms: IHA Medical Group
Trinity Health IHA Medical Group is offers a number of the most-commonly requested patient forms in an electronic version. You will find several forms below which may be completed by hand or electronically after saving a copy to your desktop, prior to your next appointment. This will allow you plenty of time to complete all necessary paperwork prior to arriving at the office. If you have any questions about which forms you should fill out, please contact your office directly.
New Patient Forms Packet
Are you a new, adult patient visiting us for the first time?
Please complete these new patient forms to help us understand your medical history and healthcare needs and bring to your first appointment.
Download the New Patient PacketInternal Medicine Forms
- Acknowledgment of Financial Responsibility
- Authorization for Sharing Information - Special Consent
- Authorization for Sharing Information with a Non-Parent/Guardian
- Controlled Substance Therapy Agreement
- Financial Assistance Application
- Medicare Wellness Checkup Risk Assessment (HRA)
- Medicare Wellness Checkup Risk Assessment (HRA) LARGE print - Fill out this form if you have an upcoming appointment for a Welcome to Medicare or Medicare Wellness Visit
- Missed Appointment Policy and Financial Responsibilities
- Opioid Start Talking Form
- Physical Evaluation Form (MHSAA) - Fill out this form if completing a sports physical
- SIOH Screening Tool
Family Medicine Forms
- Authorization for Sharing Information - Special Consent
- Authorization for Sharing Information with a Non-Parent/Guardian
- Acknowledgment of Financial Responsibility
- ADHD Vanderbilt Assessment Form: Parent
- ADHD Vanderbilt Assessment Form: Teacher
- Autism Evaluation Packet
- Controlled Substance Therapy Agreement
- Financial Assistance Application
- Medicare Wellness Checkup Risk Assessment (HRA)
- Medicare Wellness Checkup Risk Assessment (HRA) LARGE print - Fill out this form if you have an upcoming appointment for a Welcome to Medicare or Medicare Wellness Visit
- Missed Appointment Policy and Financial Responsibilities
- Opioid Start Talking Form
- Physical Evaluation Form (MHSAA) - Fill out this form if completing a sports physical
- SIOH Screening Tool
Obstetrics and Gynecology Forms
- Acknowledgment of Financial Responsibility
- Behavioral Health Standard Consent Form
- Financial Assistance Application
- OB/GYN History Form
- Opioid Start Talking Form
- Social Worker Financial Responsibility Waiver
Pediatric Forms
- Acknowledgment of Financial Responsibility
- ADHD Vanderbilt Assessment Form: Parent
- ADHD Vanderbilt Assessment Form: Teacher
- Authorization to Treat Minors
- Authorization for Sharing Information - Special Consent
- Authorization for Sharing Information with a Non-Parent/Guardian
- Autism Assessment Packet
- Controlled Substance Therapy Agreement
- Health History
- Physical Evaluation Form (MHSAA)
- Screening Questionnaire for Immunizations
- MyChart Access – Teen
- SIOH Screening Tool
Behavioral Health Forms
Patients 18 years+:
- Standard 18 years+: Consent to Treat
- No Show Policy
- Acknowledgment of Financial Responsibility - Waiver/Good Faith Estimate
Patients 0 - 17 years:
- Standard 0 - 17 years: Consent to Treat
- No Show Policy
- Acknowledgment of Financial Responsibility - Waiver/Good Faith Estimate
- MyChart Access
- Minor Authorization to Share
Video Appointment and Telephone Appointment Forms
- HIPAA Form
- Master Consent Form
- No Show Policy and the Acknowledgement of Financial Responsibility
Spanish Forms
- Vista de Bienestar de MedicareEvaluación de riesgo para la salud
- Autorización para
- Compartir información
- Pediatría
- Autorización de tratamiento para menores
- Reconocimiento de responsabilidad económica
No Show Policy
Authorization for Release of Information
This form is used to request that a health care provider (physician, practice, hospital, etc.) to release your medical records, either to the patient, a third party (such as an employer or insurance company), or both.
Authorization for Sharing Information
This form allows your protected health information to be shared with a person that you choose. This includes or excludes special consent information (HIV (Human Immunodeficiency Virus) related illness, testing OR Sexually Transmitted Diseases; AIDS (Acquired Immunodeficiency Syndrome) or ARC (AIDS Related Complex); Information about Alcohol and Drug Abuse Treatment; Information about Mental Health Services and Social Services. In addition, other private information such as pregnancy or contraceptive management information can be shared.