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Patient Forms

If you are visiting St. Mary’s Medical Clinic for the first time, we offer our required medical forms for you to print and complete before your visit for your convenience. They are in PDF format and can be viewed using the free Adobe Reader download.

• Patient Registration Form
• Health History Form
• HIPAA Form
• Medication List
• Authorizations for Release of Medical Information Form
• Registro Del Paciente
• Preguntas y quejas
• Forma Del Consentimento

Fees, Billing and Insurance
The goal of St. Mary’s Medical Clinic is to deliver the highest quality medical care to our patients in the most efficient and effective manner. To do this, we must run an efficient office from a business perspective. Below is a brief summary of our office policies concerning payment of fees:

Private Insurance: Payment is due at the time of service for all office charges. After your visit, you will receive an invoice detailing the services performed during your visit, the associated charges and the diagnosis. The invoice contains all the information needed to file with your insurance. We also require a copy of your insurance card. For hospitalization, we allow 30 days for your insurance to provide payment. After this time, we will request payment of charges by you.

HMO/PPO Patients: If you belong to an HMO or PPO, please inform the receptionist upon your arrival. You will be required to make to co-payment at the time of your visit.

Medicare: We are participating providers in the Medicare program. If you have Medicare and supplemental policy, we will be happy to process your paperwork. However, you will be responsible for paying your deductible and any non-covered charges. For your convenience, we also accept cash, checks, Visa, or MasterCard.