Yankton Medical Clinic
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Please let us know what type of information you need from us or how we can help you! If requesting Release of Information, Designated Person of Representation, New Patient Registration or Name Change, please download the forms below. For all other inquiries simply submit the form below and we will respond.


ROI (Release of Information) form instructions:
Please click on the Authorization for Release of Information form link below. Print the form and complete with information needed, how soon needed, and please sign and date. Return the form to Yankton Medical Clinic, P.C. by fax (605-665-0546) or by mail (1104 W. 8th St. Yankton, SD 57078). Medical records cannot be released without a completed and signed authorization form.


ROI (Release of Information) form


DPR (Designated Person of Representation) form instructions:
If you would like us to have a Designated Person of Representation on record, please click on the Designated Person of Representation form link below. Print the form and complete with the person(s) listed you want to have access to your private, protected health information. Sign and date where indicated. Return the form to Yankton Medical Clinic, P.C. by fax (605-665-0546) or by mail (1104 W. 8th St. Yankton, SD 57078). Medical records cannot be released to any person, other than yourself, without a completed and signed Designated Person of Representation form.


DPR (Designated Person of Representation) form


New Patient Registration:
Please click on the New Patient Registration form link below. Print the form and complete with information needed and please sign and date. Return the form to Yankton Medical Clinic, P.C. by fax (605-665-0546) or by mail (1104 W. 8th St. Yankton, SD 57078).


New Patient Registration form


Name Change:
Please click on the Name Change form link below. Print the form and complete with information needed and please sign and date. Return the form to Yankton Medical Clinic, P.C. by fax (605-665-0546) or by mail (1104 W. 8th St. Yankton, SD 57078).


Name Change form


All Other Inquiries:


Type of Information (select one):
Name:
Address:
City:
State:
Zip Code:
Phone Number:
E-Mail Address:
Additional Comments: