Forms

Good Faith Estimate

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

Medical Release Form

Medical Records Request Download Form

English FA Application

Financial Assistance English Application - Download Form

Form 4506T - English

Financial Assistance Form
4506-T
Request for Tax Return Transcript - Download Form

Spanish FA Application

Spanish FA Application - Download Form

Spanish Form T

Financial Assistance Form
4506-T
Request for Tax Return Transcript - Download Form

Consent to Treat Minor

Consent to Treat Minor Form - Download Form

Stakeholder Agreement Form

We want to continue to work with our Community Based Organizations and businesses. Download this form to partner with Heartland Health Services.

Community Partner Referral Form

Community Partners can now download a referral form for consumer or patient assistance from our Community Health Workers.