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