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Patient Forms
For your convenience, we have made frequently used patient forms available online. Completed forms can be mailed to:
Mid Dakota Clinic PrimeCare
Attn: Front Office Supervisor
PO Box 5538
Bismarck, ND 58506
You may also drop completed forms off at the Main Clinic at 401 N. 9th St. or fax them to (701) 530-5934.
All forms are in Adobe Acrobat and require the Adobe Reader which can be downloaded here.
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Authorization of Release of Information to Family
File Size: 27.52 kb
Use this form to allow a family member to communicate with your doctor or nurse. Please note this release does not entitle a family member to receive your written medical information.
Authorization for Release of Patient Information
File Size: 93.6 kb
Use this form to request a transfer of records to an individual, business entity or another healthcare facility.
Patient Information Record
File Size: 8.12 kb
Use this form to register as a new patient.
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