Customer Service General Inquiry Form
Members and Providers may contact Hill Physicians Customer Service by phone or mail.
Health Navigators Preventive Care Services Form
Use this form to request preventive care support from our Health Navigators.
HMO Member Vaccination Reimbursement Form
Fill out the HMO vaccination reimbursement form and submit your receipts online.
Pharmacy Consultation Form
Members may request a free pharmacy consultation to review your medications.
Member Services Forms
HMO Member Reimbursement Form: For vaccines: Flu, Shingles, and Tdap*
Submit a reimbursement request for flu, shingles, or Tdap vaccines (HMO members) if you paid out of your own pocket to receive the flu, Tdap** (Boostrix®, Adacel®, Tenivac®, TDVAX®), or shingles shots* (Zostavax®, Shingrix®) at a pharmacy.
*Hill Physicians does not reimburse for tetanus/whooping cough or shingles shots for Medicare members.
Cancer Screening Help Request Form
We can assist you in making your screening appointment, getting you a referral, or sending you a test kit. Request help with cancer screening from our Health Navigators.
Request for an Accounting of Disclosures
To request an accounting of disclosures of your health information, submit a request for an accounting of disclosures.
Alternative Communication Request
To request an alternative form of communication from Hill Physicians, submit an alternative communication request.
Request to Restrict the Use or Disclosure of Your Health Information
To request a restriction on the use or disclosure of your health information, submit a request to restrict the use or disclosure of health information.
Authorization for Release of Medical Records
To request access to your patient health information, you first need to complete the authorization form for release of medical information.
Request to Amend the Designated Record Set (California Addendum)
To request an amendment to the designated record set, submit a request to amend the designated record set (California addendum).
Personal Healthcare Forms
These forms should help you be an active participant in your care.
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. Additional guidance, state-specific advance directive forms, and multilingual resources are available through the PREPARE for Your Care website at prepareforyourcare.org.