Patient Forms
Welcome to the RCMS family! It is our mission to provide the highest quality healthcare to all of our patients. Find helpful forms and information here.
It is important that all forms in your file are accurate and up to date. Please help us keep your records up to date by reporting any recent changes.
Below are some of our most commonly used forms in a convenient downloadable pdf format:
It is important that all forms in your file are accurate and up to date. Please help us keep your records up to date by reporting any recent changes.
Below are some of our most commonly used forms in a convenient downloadable pdf format:
Registration
If you are a new patient, please fill out the Patient Registration form and bring it with you to your appointment. También está en español.
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Financial Assistance
Eligible patients in our service area (Elk to Timber Cove) are eligible to apply for the Sliding Scale Discount program. To apply fill out the Patient Financial Screening Form below:
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To be eligible, please provide proof of income within 30 days of submitting your application. Acceptable forms include:
- W-2 form
- Last year’s income tax return
- Most recent pay check stub
- Unemployment check stub
- Notification of Benefit for disability income
- Social Security payment letter or bank statement showing proof of direct deposit of Social Security income
- If self-employed, either prior year’s Schedule C income statement or quarterly profit and loss statement
- Worker’s Compensation stub or proof of direct deposit
- Signed personal letter stating declaration of income such as income from boarders, odd jobs, or assistance from charity, family for friends
Patient Medical History
First time patients, please fill out the medical history form below:
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Release of Information
If you would like to release your RCMS records to another health care facility please fill out the form below:
| release_from_rcms.pdf |
To Authorize the release of your records from another facility to RCMS please fill out this form:
| release_to_rcms.pdf |
