Patient Forms

For your convenience, we have made frequently used patient forms available online. All forms require the Adobe Reader which can be downloaded here .

Unless otherwise indicated. you may fax completed forms to 701.712.4097, drop them off at the Main Clinic at 401 N. 9th St., or mail them to:

Mid Dakota Clinic
Attn: Medical Records Department
PO Box 5538
Bismarck, ND 58506-5538

Authorization for Release of Information Form Download here
Authorizes the release of your medical information to yourself or another party.

Authorization for Release of Information to Family Form Download here
Authorizes the release of your medical information and billing to a family member, or authorizes the release of billing information only on paper.

Authorization to Treat a Minor Form Download here
A Parent or Legal Guardian must give informed consent for Mid Dakota Clinic to examine and treat a minor. If you cannot attend the appointment, then: (a) you may appoint another responsible adult to bring the child to the appointment; or (b) if your child is 15 or older, your child may come to the appointment without you. You must, however, complete and sign the Authorization to Treat a Minor form and return it to the Clinic on or before the scheduled appointment. You must also be available by phone, in case the provider needs to contact you.

Email Communication Consent Form Download here
Provides consent for Mid Dakota Clinic to receive certain types of patient information by email.

Patient and Family Advisor Application Download here
Patient and family advisors participate on an advisory council along with caregivers, doctors, nurses, and staff to discuss and plan changes to improve quality of care and safety at Mid Dakota Clinic.

Patient Notice and Assignment of Insurance Benefits Form Download here
This notice describes how medical information about you may be used and disclosed and how you can access this information.

Preparing for Your Clinic Visit Form Download here
We want to know what symptoms, questions, or concerns matter most at your visit. Use this convenient form to identify three main topics to discuss with your provider and any other services you may need.

Sports Physical Form Download here
Most youth sports programs follow the guidelines of the North Dakota High School Activities Association (NDHSAA) which requires a physical examination be completed on or after April 15 to be valid for participation the following school year. A parent/guardian must accompany children ages 14 and younger. If your child is 15 or older, your child may come to the appointment without you. You must, however, complete and sign the Authorization to Treat a Minor form (included) and return it to the Clinic on or before the scheduled appointment. You must also be available by phone, in case the provider needs to contact you.

Patient Forms

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