Here you will find various forms that you, or one of our patients, may need to complete while conducting business with STEEMCC. The forms can be downloaded and filled out, or they can be filled out online and printed to your printer. Once the forms have been completed, sign all applicable forms and return them to us. In order to avoid any delay in processing, be sure to have the forms delivered to the appropriate office. One of our staff members is available to assist and guide you if you need help in selecting and completing the correct form. Just click on "Get this form in..." to view it in the language of your choice; fill it out on line, and download or print it.
Signs and Symptoms Form - During this COVID19 pandemic, each time an individual comes into the facility, he/she is required to fill out this form. This form is for patient, staff, and visitors. This form will be given to the triage center and a staff member on duty will check individual’s temperature. Please answer the questions as honestly as possible. Get this form in English. Get this form in Spanish. Get this form in French/Haitian Creole.
Patient Disclosure Form - This enables patients to receive and/or release his/her records to government entities, outside providers and the patient.
If patient is releasing his/her record to another individual, he/she will have to bring a government issued I.D. Normally the form expires in 90 days and processing time is 5 to 10 business days. Please note all copies of medical records are $1.00 per page except immunizations and SSA Letters. Replacement of hard copy immunization card cost $17.00. Get this form in English. Get this form in Spanish. Get this form in French/Haitian Creole.
Medical Treatment of a Minor Form - This form is a legal document providing someone other than the parent or legal guardian temporary rights to seek and provide healthcare and make healthcare decisions, at STEEMCC, on behalf of his/her child. This form needs to be notarized. For corporations and government entities you can bring in documents with the company or government logo.
Get this form in English. Get this form in Spanish. Get this form in French/Haitian Creole.
This health center receives HHS funding and has Federal PHS deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.