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 Form
Members may request a free consultation with one of our pharmacists to review your medications here ...
Member Services Forms
HMO Member* Reimbursement Form: For vaccines: Flu, Shingles, and TDaPPlease 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. |  |
Cancer Screening Help Request Form:
We can assist you in making your screening appointment, getting you a referral or sending you a test kit. Please fill out the form and fax or mail it to our Health Navigators.
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Request for an Accounting of Disclosures:To request an accounting of disclosures of your health information, please complete and submit the request form |  |
Alternative Communication Request:To request an alternative form of communication from Hill Physicians, please complete and submit the request form |  |
Request to Restrict the Use or Disclosure of your Health Information:To request a restriction on the use or disclosure of your health information, please complete and submit the request form. |  |
Authorization for Release of Medical Records To request access to your patient health information, you first need to fill out a release form. |  |
Personal Healthcare FormsThese forms should help you be an active participant in your care
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