Forms

Patient and Community Forms

Patient and Community Resources

  • Good Faith Estimate
  • 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
  • Consent to Treat Minor Form

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Patient Forms

Good Faith Estimate

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 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

Consent to Treat Minor

Consent to Treat Minor

Consent to Treat Minor Form - 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.