Patient Forms
Elkhart Clinic and Privia Medical Group specific forms providing the latest versions of information for all of your health needs.
Notice of Privacy Practices
Describes how health information about patients may be used and disclosed, and how they can get access to individually identifiable health information. Please review this notice carefully.
Authorization for Release of Medical Information
Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
Authorization and Consent for Treatment
All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.
Preferred Contacts
Patients are encouraged to complete and return their Preferred Contacts Form, but it is not a requirement for treatment.
Financial Policy
This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.