Resources

Quick Reference Guide 

The following forms, releases, applications, contracts, consents, etc. are readily available for download below:

For partners:

Sample MOU Sample MOU (17 KB)


For medical providers office managers:

At A Glance At A Glance (216 KB)

New Patient Cover Sheet New Patient Cover Sheet (1075 KB)

Noncompliant Patient Form Noncompliant Patient Form (201 KB)

Provider Manual Provider Manual (538 KB)

Specialty Referral Form Specialty Referral Form (1076 KB)


For physician recruitment:

Fact Sheet Fact Sheet (138 KB)

How It Works Map How It Works Map (107 KB)

Practice Information Form Practice Information Form (56 KB)

Provider Information Form Provider Information Form (60 KB)

Sample MOU Sample MOU (17 KB)

Script Script (17 KB)


Patient care coordination: 

Authorization for Use and Disclosure of Protected Health Information Authorization for Use and Disclosure of Protected Health Information (178 KB)

Confirmation of Paid Living Expenses Confirmation of Paid Living Expenses (364 KB)

Contract for Participation Contract for Participation (88 KB)

Doctors Care Program Group Information Session (GIS) Doctors Care Program Group Information Session (GIS) (1449 KB)

Email Protocol and Consent Email Protocol and Consent (122 KB)

Health and Mental/Behavioral Health Intake Survey Health and Mental/Behavioral Health Intake Survey (451 KB)

Program Application (pre-intake interview) Program Application (pre-intake interview) (153 KB)

Release of Information Authorization (HIPAA Form) Release of Information Authorization (HIPAA Form) (260 KB)

Request for Documentation Checklist Request for Documentation Checklist (233 KB)

Residence Confirmation Residence Confirmation (176 KB)

Sample Termination Letter Sample Termination Letter (22 KB)

Sample Warning Letter Sample Warning Letter (29 KB)

Self-Employment Profit & Loss Form Self-Employment Profit & Loss Form (100 KB)

Sliding-Fee-Scale Program Guidelines Sliding-Fee-Scale Program Guidelines (175 KB)


For volunteers: 

Other community resources: 

Dental Brochure Dental Brochure (251 KB)

Healthy Living Brochure Healthy Living Brochure (227 KB)

Medical Brochure Medical Brochure (187 KB)

Mental Health Brochure Mental Health Brochure (156 KB)





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