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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.
To Complete a Fillable PDF:
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Click the PDF Link below
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PDF will open in a new window
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Click on first box and complete
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Tab through each selection until complete
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Click "Save As" to save your document
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Print and bring to appointment OR email document to contact@mountainvalleys.org
Medicare Annual Wellness Visit
Health Risk Assessment
Sliding Fee Application
English
*This form is ONLY required for Annual Wellness Visits.
Medicare Annual Wellness Visit
Health Risk Assessment
Spanish
Sliding Fee Application
Spanish
Self-Declaration of Income
English
Self-Declaration of Income
Spanish