Patient Forms

For your convenience, we have made frequently used patient forms available online. Completed forms can be mailed to:

Mid Dakota Clinic
Attn: Front Office Supervisor
PO Box 5538
Bismarck, ND 58506-5538

You may also drop completed forms off at the Main Clinic at 401 N. 9th St. or fax them to 701.712.4097.

All forms are in Adobe Acrobat and require the Adobe Reader which can be downloaded here.

Authorization for Disclosure of Protected Health Information
Authorizes the release of your medical information to yourself or another party.

Authorization for Release of Information to Family
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
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.

Patient and Family Advisor Application
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.

Sports Physical Form
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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