VMC Forms Directory

 Permission to Treat

• Consent to Care and Treatment (Form 20-1193) 
  • English
  • Arabic العربية 
  • Russian Pусский
  • Spanish Español 
  • Vietnamese Tiếng Việt
   
• Permission To Treat A Minor Without A Parent Or Guardian Present (Form 86-0340)

 

 Property

• Patient Property Notice (Form 87-9162) 
  • English
  • Arabic العربية 
  • Russian Pусский
  • Spanish Español 
  • Vietnamese Tiếng Việt
   
• Permission To Treat A Minor Without A Parent Or Guardian Present (Form 86-0340)

 

Important Notices

• Important Message from Medicare (IMM)
• Important Message from Tricare
• Electronic Communications Acknowledgement (Form 20-1226)
  • English
  • Arabic العربية 
  • Russian Pусский 
  • Spanish Español  
  • Vietnamese Tiếng Việt 
      

Financial Policies & Agreements

 UWM|VMC Financial Agreement & Consent for Disclosure (Form 20-1192)

• English  
• Arabic العربية  
• Russian Pусский  
• Spanish Español  
• Vietnamese Tiếng Việt

Cost Estimates

• Estimate Your Cost of Hospital Care (online form)

 

UWM|VMC Financial Assistance Program

• Eligibility & Policy | Application Instructions | Plain Language Summary

• Federal Poverty Guidelines
• Hospital Providers who provide services covered by the UW Medicine Financial Assistance Policy:
  • Harborview Medical Center Provider Listing
  • UW Medical Center Provider Listing
  • Northwest Hospital Provider Listing
  • Valley Medical Center Provider Listing                                              
   

     Third-Party Financial Assistance

• Medicaid & Public Assistance Programs

Medical Emergency & Estate Planning

• Washington State Death with Dignity Act (Initiative 1000)

• Durable Power of Attorney for Healthcare
• Health Care Directive: English | Spanish Español

Medical Records

• Patient Authorization to Release Protected Health Information / view fees (Form UH0626)
• Request to Consider Additional Privacy Protection for Personal Health Information (Form 96-23372)
• Request for Correction or Amendment of Medical Record (Form UH2078)

Patient Rights & Responsibilities

• Notice of Nondiscrimination and Accessibility
• Patient Rights & Responsiblities Policy
  • English (policy 96-23387-VMC-PatientRights-English)
  • Spanish Español (policy 96-23387-VMC-PatientRights-English)
  • Vietnamese Tiếng Việt  (policy 96-23395-VMC-PatientRights-Vietnamese)   
                     

Joint Notice of Privacy Practices

• English
• Arabic العربية
• Chinese 中文
• Russian Pусский 
• Somali Somali
• Spanish Español 
• Vietnamese Tiếng Việt 

Health History

• Adolescent Female Health History (Form 87-9038)
• Adult Female Health History (Form 87-9035)
• Adult Male Health History (Form 87-9036)
• OB-GYN Registration for Hospital Care (Form 96-1059)
• Pediatric/Child Health History Birth to 8 Years (Form 87-9132)
• Prenatal History Questionnaire (Form 87-9133)

MyChart

• Proxy Consent for Minors 

Cardiac Rehabilitation

• Adult Health History Survey (Form 87-9107)
• Risk Factor and Lifestyle Questionnaire (Form 87-8457)

 

Occupational Health

• New Patient Registration Form
• Consent to Treatment (Form 96‐23365)