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 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 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.
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.
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 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. Other formats and multi-lingual forms are available at iha4health.org here...