Member Forms

​​Member Reimbursement Forms

Hill Physicians encourages our members to be vaccinated against common ailments and infectious diseases such as influenza. Check with your doctor on scheduling your flu shot and any other preventive screenings or immunizations for you and your family members.

Flu Shot Reimbursement Form
​Hill Physicians recommends getting your flu shot at your doctor’s office. However, if you prefer to get your flu shot at a retail location, Hill Physicians will reimburse the cost, up to $60 per Hill member.
Shingles Vaccination Reimbursement
Hill Physicians members recommended for a shingles vaccination who receive either Shingrx or Zostafax from physicians outside of our network may request reimbursement using this form.
Non-Medicare Member Tdap-Adacel Reimbursement Form - Pending update for 2018
For Members who do NOT have Medicare Part D. You may request reimbursement for the whooping cough vaccine.

​Personal Healthcare Forms

Being an active participant in your healthcare should include keeping track of your medical records and history. The following forms may assist you.

Authorization for Release of Medical Records
​To request access to your patient health information, you first need to fill out a release form.​

​Advance Directive​
For members to state what kind of healthcare you want if you become very sick and are unable to speak for yourself.

This form was created for San Francisco Public Health. Other formats and multi-lingual forms are available at here...

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