Forms
Customer Service General Inquiry Form
Members and Providers may contact us by phone or mail.
Health Navigators Preventive Care Services Form
Use this form to request help from our Health Navigators.
HMO Member Vaccination Reimbursement Form
Fill out the reimbursement form and submit your receipts online.
Pharmacy Consultation Form
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Member Services Forms
HMO Member Reimbursement Form: For vaccines: Flu, Shingles, and Tdap*
Please use this form if you paid out of your own pocket to receive the flu, Tdap** (Boostrix®, Adacel®, Tenivac®, TDVAX®), or shingles shots* (Zostavax®, Shingrix®) at a pharmacy.
*Hill Physicians does not reimburse for tetanus/whooping cough or shingles shot for Medicare members.
Cancer Screening Help Request Form:
We can assist you in making your screening appointment, getting you a referral or sending you a test kit. Please fill out the form and submit it to our Health Navigators.
Request for an Accounting of Disclosures:
To request an accounting of disclosures of your health information, please complete and submit the request form.
Alternative Communication Request:
To request an alternative form of communication from Hill Physicians, please complete and submit the request form.
Request to Restrict the Use or Disclosure of your Health Information:
To request a restriction on the use or disclosure of your health information, please complete and submit the request form.
Authorization for Release of Medical Records
To request access to your patient health information, you first need to fill out a release form.
Request to Amend the Designated Record Set (California Addendum)
To request submit a request to amend the designated record set, please fill out this form.
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Personal Healthcare Forms
These forms should help you be an active participant in your care
Advance Directive
For members to state what kind of healthcare you want if you become very sick and are unable to speak for yourself. This form was created for San Francisco Public Health. Other formats and multi-lingual forms are available at iha4health.org here.
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