Forms

Let us know what type of information you need from us or how we can help you! If requesting a release of information, designated person of representation, new patient registration or name change,  download the forms below. Once completed, bring or send them to the clinic for processing.

To contact your provider, or ask a billing question use the patient portal to send a message.

 

We take the protection of your health information seriously and take steps to ensure your privacy.  You can review our health privacy policy at any time.

Print and sign any forms you need and send completed information to: 

Yankton Medical Clinic, P.C.:
1104 W. 8th St. 

Yankton, SD 57078 

 Or By fax: 605-665-0546

 

Release of Information (ROI) form instructions:
Open the authorization for release of information form link below.

Medical records cannot be released without a completed and signed authorization form.

ROI (Release of Information) form

Designated Person of Representation (DPR) form instructions:
If you would like us to have a designated person of representation on record, click on the designated person of representation form link below. 

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:
Select the new patient registration form link below. 

 New Patient Registration form     New Patient Registration form (Spanish)

Name Change:
Select the name change form link below.

Name Change form