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Patient Forms

The following forms are available for you to print and fill out before your scheduled appointment. If you need assistance, please contact your local clinic or email contact@mountainvalleys.org. Click here for our Notice of Privacy Practices.

To Complete a Fillable PDF:

  • Click the PDF Link below

  • PDF will open in a new window

  • Click on first box and complete

  • Tab through each selection until complete

  • Click "Save As" to save your document

  • Print and bring to appointment OR email document to contact@mountainvalleys.org

Medicare Annual Wellness Visit

Health Risk Assessment

Sliding Fee Application

English

Self-Declaration of Income

English

*This form is ONLY required for Annual Wellness Visits.

Medicare Annual Wellness Visit

Health Risk Assessment

Spanish

Patient Registration Form

English

Sliding Fee Application

Spanish

Patient Registration Form

Spanish

Self-Declaration of Income

Spanish

Forms may be submitted to 
contact@mountainvalleys.org

Your privacy is a priority. Your mobile number will not be sold or shared with third parties or affiliates for marketing or promotional purposes. We will not use your number for unrelated marketing without your express written consent. We collect mobile phone numbers to communicate with patients via SMS and/or RCS text messages for purposes such as appointment reminders, billing notifications, and care coordination. Message and data rates may apply and message frequency may vary. Carriers are not liable for delayed or undelivered messages. Text messages sent via SMS and RCS channels are not fully secure and may not be HIPAA-compliant; however, we take reasonable precautions to safeguard your privacy by restricting the content of these messages to non-sensitive notifications. Any messages containing detailed Protected Health Information (PHI) will be sent via a separate, secure messaging channel.
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