Patient Forms
Save time by filling out your patient forms ahead of your appointment.
Patient Forms
If you are new to Signature Health, you’ll need to fill out our new patient paperwork. You have the option to fill out the forms before your appointment, to save time. We also use DocuSign to send forms via email for patients to complete and sign electronically.
To complete your patient forms ahead of time, please print the below forms, fill them out, and bring them to your first appointment.
New Patient Forms:
Other Forms (if needed):
- Medical Records Request Form (4/8/20)
- Release of Information Form
- Revocation of Consent to Release Information Form
- Grievance Report Form
- Parent or Court-Appointed Guardian Request for MyChart Caregiver Access (for minor patients or adult patients with guardian)
- Request for MyChart Caregiver Access (for adult patients)
Patient Handbooks (Revised 6/1/22):
The handbook includes Patient Rights and the Grievance Policy.
Fee Schedule & Sliding Fee Scale for 2022
- Fee Schedule Agreement Form (6/1/22)
- Sliding Fee Scale - FQHC & Title X | Español
- Sliding Fee Scale - Ryan White Program | Español
Notice of Privacy Practices (Revised 5/25/21):
When Signature Health transitioned to a new electronic health record system (Epic) in 2021, we updated our Notice of Privacy Practices to include information about our participation in the organized healthcare arrangement called OCHIN. OCHIN helps with patient referrals, continuity of care, healthcare operation, and other activities. We may also participate in Health Information Exchanges that will allow patient care providers to quickly access medical information necessary for patient treatment. More information about these changes can be found in the Notice of Privacy Practices.
Notice of Nondiscrimination
