Forms

For information about requesting or sending medical records, view the Medical Records page

To view these forms you may need to download and install Adobe Reader.

• Release of Information (Authorization) Download and complete this form to ask Sindecuse Health Center to release medical records to you, or a designated person or another medical provider. Return via fax to (888) 979-8229.
• Consent for Telehealth - Primary Care Services
• Consent for Telehealth - Counseling and Psychiatric Services
• Informed Consent for Counseling, Psychiatry, Social Work, and Dietitian
• Massage Therapy Patient Information
• Medical History
• Medical Treatment Authorization for Minors
• Notice of Privacy Practices  The Health Insurance Portability and Accountability Act Privacy Rules provide important protection for your health information. The Privacy Rules apply to the use and disclosure of Protected Health Information by entities providing medical care and treatment. Except in a few specific  circumstances, health care providers must obtain your authorization to share information they collect and store. 
• Sports Medicine Patient Health History

For more information call (269) 387-3287.