Forms

Patient and Community Forms

Patient and Community Resources

  • Heartland Medical Release Form
  • English Financial Assistance Form 
  • Form 4506T - English
  • Spanish Financial Assistance Form
  • Form 4506T - Spanish
  • Stakeholder Agreement - Community Partner
  • Community Partner Referral Form

Sort By Category

Patient Forms

Medical Release Form

Medical Release Form

Medical Records Request Download Form

English FA Application

English FA Application

Financial Assistance English Application - Download Form

Form 4506T - English

Form 4506T - English

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

Spanish FA Application

Spanish FA Application

Spanish FA Application - Download Form

Spanish Form T

Spanish Form T

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

Community Partner Forms

Stakeholder Agreement 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 Partner Referral Form

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