Member Forms

Secure Online Forms

Customer Service General Inquiry Form
​Members and Providers may contact us online through our secure Online Inquiry Form here...

HMO (Non-Medicare) Member Vaccination Reimbursement Form
Fill out the reimbursement form and submit your receipts online... 

Pharmacy Consultation Request Form
Hill Physicians is pleased to provide one-on-one pharmacy consultations over the phone to our members.​ Request an appointment here...

​​​​Member Reimbursement

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

HMO member* reimbursement Form: For vaccines: Flu, Shingles, and TDaP
Please use this form if you paid out of your own pocket to receive the flu, tetanus / whooping cough (Boostrix®, Adacel®), or shingles shot (Zostavax®, Shingrix®) at a pharmacy.
*You may only use this form if you have health insurance that is not through Medicare.

Personal Healthcare Forms

These forms should help you be an active participant in your care

​​Authorization for Release of Medical Records

​To request access to your patient health information, you first need to fill out a r​elease 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 iha4health.org here...