Contact Us

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. For all other inquiries simply submit the form below and we will respond.

Release of Information (ROI) form instructions:
Open the authorization for release of information form link below. Print the form and complete with information needed, how soon needed, and 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

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. 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:
Select the new patient registration form link below. Print the form and complete with information needed and 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     New Patient Registration form (Spanish)

Name Change:
Select the name change form link below. Print the form and complete with information needed and 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