patient registration paperwork

You can now complete your patient registration paperwork online:

• Complete the patient registration form

Please note: It may take up to 2 business days for your registration to upload into our system.  Afterwards, please call our clinic to schedule an appointment.  We are not automatically notified when you have completed the registration. Miigwech/Pidamaya!

Sliding fee application

NACC provides care regardless of ability to pay. You may qualify for reduced cost of care if you are uninsured and make less than 200% of Federal Policy Guidelines.

• Complete the Sliding Fee Discount Application

Consent + Patient health history forms

Transportation

RELEASE OF INFORMATION

If you have submitted a request for the release of your medical records, you can check the status by contacting ShareCare, our release of information partner.

📞 Phone: 858-244-1811
📧 Email: customersevicehds@sharecare.com

• Release of information form

CONSENT FORMS

• CONSENT FOR TELE-HEALTH: To sign your tele-health consent, please complete this form

DENTAL FORMS

• Dental Health History

BEHAVIORAL HEALTH FORMS

• GAD-7 Anxiety Screening

• PHQ-9 Depression Screening

• WHODAS 2.0 Disability Assessment

• PC-PTSD

• CAGE-AID Substance Use Screener

Before filling out this form, please contact our Transportation Coordinator at (612) 599-1675

• Transportation Request Form
  

NACC’s Notice of Privacy Practices