Save Time

Be prepared for your first appointment or next visit by printing out and filling out your forms ahead of time. No printer? Not a problem! We have physical copies in the office and can help you as needed.

Patient Registration Form

Before receiving any care, you must fill out this patient registration form.

Purchased Referred Care and Medicare Relief Block Grant Application

This form is for when you need to apply for a grant for medicare relief.

Medical Release Form

Before receiving any care, you must fill out this medical release form.

Denials and Appeals Information

This form includes the contact information where you would send an appeal if you were denied PRC.

Authorization for Use or Disclosure of Protected Health Information

This form is required for those who need to transfer medical care or information.

Grievance/Complaint Form

Have a complaint or concern? Fill this form out to be submitted to our Health Director. 

Contact us

Call Us

Send Us A Fax

715-478-5904

Our Location

3144 VanZile Road
Crandon, WI 54520

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