New-Patient-Information-Form

Patient Forms

Thank you for selecting Boston Mountain Rural Health Center for your primary care. To schedule an appointment, Call us today at one of our convenient locations in Marshall, Clinton, South Side, Center Ridge, Yellville, Mountain View, Huntsville, Green Forest, Jasper, Deer, and Harrison Arkansas, and our friendly staff will gladly make an appointment for you, or you can request an appointment online.

Once you have made your initial appointment, you may pre-register by downloading, printing, and completing the forms below. Please be sure to bring them with you to your first visit. Completing the forms prior to your visit will help speed up the new patient registration process.

Online Form:

• Patient Satisfaction Survey - English
• Patient Satisfaction Survey - Spanish

Downloadable Forms:

• New Patient Information Form - English
• New Patient Information Form - Spanish
• Authorization to Release Protected Health Information
• Medication Authorization Form
• HIPAA - English
• HIPAA - Spanish
• Notice of Privacy Practices Pamphlet
• Consent to Treatment (Adult)
• Consent to Treat a Minor and Authorization Form - English
• Consent to Treat A Minor and Authorization Form - Spanish
• New Patient Medical History Form (Minor)
• Cancellation and No Show Patient Form
• Consent for TeleHealth Services
• Dental Health History Form
• Patient-Centered Medical Home (PCMH) 
• Statement of Income
• Patient Portal Handout
• Advanced Directives Documents
• Sliding Fee Household Verification - English & Spanish
• SHARE Patient Flyer - English
• SHARE Patient Flyer - Spanish
• SHARE Opt-Out Form - English
• SHARE Opt-Out Form - Spanish

Please note: It may take a few minutes to load the forms if you are using a slow internet connection. If you are unable to view the forms, you may need to download Adobe Acrobat for free by clicking on the icon below.