Important Forms

Every form below is available as an accessible online page (preferred) with a printable/downloadable PDF version. Online forms can be completed on any device and work with screen readers and keyboard navigation.

New Patients

Release of Medical Records

Release of Patient Medical or Dental Information Form

Open online (English) | Open online (Spanish) | Download PDF (English) | Download PDF (Spanish)

Sliding Fee Discount Program

If you are applying for our Sliding Fee Discount Program, you will need to complete the following:

Sliding Fee Discount Application

Open online (English) | Open online (Spanish) | Download PDF (English) | Download PDF (Spanish)

List all family members and dependents living in your household. A Family is one or more persons living in one dwelling place who are related by blood, marriage, or law. A Dependent is someone who lives in your household and qualifies as a dependent for federal tax purposes.

Proof of Income (POI)

You will also need proof of income for all working family members for the past 30 days. We accept check stubs, SSI or Disability award letters, Child Support or Alimony orders, or Unemployment compensation. If you do not have any of these, the following alternative options may apply:

If you do not receive check stubs or have recently started a new job, please have your employer complete this form. It must be dated within fourteen (14) days of your scheduled appointment.

This is a signed form indicating your net income for the past month. You will also need to provide all of the following:

Pages 1 and 2 from Current Year Tax Returns
Schedule C, E, or F from Current Year Tax Returns
Bank statement from the past 30 days

Alternative Income Form

Open online (English) | Open online (Spanish) | Download PDF (English) | Download PDF (Spanish)

This is a signed form indicating that someone is supporting you at this time. To be eligible to use this form you must be:

Eighteen (18) or older
Unemployed
Supported by another individual (cannot be a spouse)

Premier offers a Sliding Fee Discount Program for eligible patients who are uninsured or underinsured. Discounts are based on income and household size. Proof of income must be presented to qualify.

Examples at the deepest discount level:

Primary Care & Medical Visits: $45
Behavioral Health Visits: $30

Important Forms

New Patients

Welcome Packet

Financial Policy

Notice of Privacy Practices

Missed Appointment Policy

Patient Bill of Rights and Responsibilities

Designation of Health Care Surrogate for a Minor

Language Assistance Services

Release of Medical Records

Sliding Fee Discount Program

Sliding Fee Discount Application

Proof of Income (POI)

Alternative Income Form