Forms

Below is an archive of accessible forms for the convenience of patients, providers and referrents. These are categorized by type of form, and some forms can be found in multiple locations. This page also includes Frequently Asked Questions (FAQ) and other informational flyers. If you have any questions, please contact us at 888-9-prairie.


New Patient Forms

Download Needs Assessment Packet

Download Adult Clinic Appointment Packet

Download Child Clinic Appointment Packet

Submit Forms Through Our Secure Email Messaging Service


Financial Forms and Information

 


Release of Information (ROI)

To request your (or your child’s) medical records to be sent from PrairieCare Inpatient or Partial Hospital Programs to another provider click here:
PrairieCare Request to Release Information (Hospital or PHP)

To request your (or your child’s) medical records to be sent from a PrairieCare Clinic or IOP visit to another provider click here:
PrairieCare Medical Group Patient Request for Medical Records (Clinic or IOP)

To request your (or your child’s) medical records from a PrairieCare Inpatient or PHP visit to be sent to you click here:
PrairieCare Patient Request for Medical Records (Hospital or PHP)

To request your (or your child’s) medical records from a PrairieCare Clinic or IOP visit to be sent to you click here:
PrairieCare Medical Group Request for Medical Records (Clinic or IOP)

To give authorization to share your (or your child’s) medical records / school information from a PrairieCare Inpatient or PHP visit with your (or your child’s) school district click here:
PrairieCare School Release of Information

To give authorization to share your (or your child’s) medical information from a PrairieCare Inpatient or PHP visit with your family or designated person click here:
PrairieCare Release of Information for Family Involvement

To give authorization to share your (or your child’s) medical information from a PrairieCare Clinic or IOP visit with your family or designated person click here:
PrairieCare Medical Group Family Involvement Release of Information

 


Privacy and Confidentiality Forms

 


Referral/ Provider Form


Frequently Asked Questions (FAQ’s)


Other Helpful Information