Patient Eligibility/Forms

Patient Forms

Forms for New Patients:

(If you are not at BHMC patient and need to be seen for a Sports Physical or an Urgent Care Visit ONLY, please scroll to Additional Forms)

Welcome Letter | Brock Hughes

Welcome Letter (for your reference)

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Notice of Privacy | Brock Hughes
Health History Form | Brock Hughes

Health History Form

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Patient Registration Form | Brock Hughes

Patient Registration Form

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Consent to Share Medical Information | Brock Hughes
Acknowledgements and Authorizations Form | Brock Hughes
HIPPA Medical Records Release Form | Brock Hughes
Medication Assistance Program Waiver | Brock Hughes

*If you are uninsured, please click the "Additional Forms for Uninsured Patients" icon located at the bottom of the page.

Additional Forms:

Urgent Care Form | Brock Hughes
Sports Physical Form | Brock Hughes
Additional Forms for Uninsured Patients | Brock Hughes

Additional Forms for Uninsured Patients

(If you DO NOT have health insurance AND are not eligible for Medicaid OR Medicare)

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