IHA is now offering a number of the most-commonly requested patient forms in an electronic version. You will find several forms below which may be completed prior to your next appointment. They may be completed by hand or electronically after saving a copy to your desktop. This will allow our patients plenty of time to complete all necessary paperwork prior to arriving at the office.
If you have any questions about which forms you should fill out, please contact your office directly.

 

Internal Medicine Forms

Family Medicine Forms

Adult History New Patient Form*

* Fill out this form if you are a new patient to
our office and bring to your first appointment

Adult Immunizations

Authorization for Sharing Information

Authorization to Treat Minor

Financial Assistance Application

Medicare Wellness Checkup Risk Assessment (HRA)**
** Fill out this form if you have an upcoming appointment for a Welcome to Medicare or
Medicare Wellness Visit

Physical Evaluation Form (MHSAA)

Release of Information Authorization

ADHD Vanderbilt Assessment Form: Parent

ADHD Vanderbilt Assessment Form: Teacher

Adult History New Patient Form*
* Fill out this form if you are a new patient to our office and bring to your first appointment

Adult Immunizations

Asthma Control Test: Ages 4 to 11 years

Asthma Control Test: Ages 12 and older


Authorization for Sharing Information

Authorization to Treat Minor

Financial Assistance Application

Medicare Wellness Checkup Risk Assessment (HRA)**
** Fill out this form if you have an upcoming appointment for a Welcome to Medicare or
Medicare Wellness Visit

Release of Information Authorization


Pediatric Forms

 Obstetrics & Gynecology Forms

ADHD Vanderbilt Assessment Form: Parent

ADHD Vanderbilt Assessment Form: Teacher

Asthma Control Test: Ages 4 to 11 years

Asthma Control Test: Ages 12 and older

Authorization for Sharing Information

Authorization to Treat Minor

Demographic Form

Health History

Physical Evaluation Form (MHSAA)

Release of Information Authorization

Screening Questionnaire for Immunizations

Adult Immunizations

Authorization for Sharing Information

Authorization to Treat Minor

Financial Assistance Application

OB/GYN History Form

Release of Information Authorization