Secure Online Forms

Customer Service General Inquiry Form

​Members and Providers may contact us by phone or mail.

Health Navigators Preventive Care Services Form

HMO Member Vaccination Reimbursement Form

Pharmacy Consultation Form

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​​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, Tdap** (Boostrix®, Adacel®, Tenivac®, TDVAX®), or shingles shots* (Zostavax®, Shingrix®) at a pharmacy.

*Hill Physicians does not reimburse for tetanus/whooping cough or shingles shot 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. Please fill out the form and submit 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 r​elease form.​​​

Request to Amend the Designated Record Set (California Addendum)

​To request submit a request to amend the designated record set, please fill out this form.

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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 here.

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