FORMS

Forms

 Our most frequently used forms can be found on this page. Please contact us if you have questions.

Registration

​Missoula Medical & BH Registration Form
Missoula Dental Registration Form

Seeley Medical & BH Registration Form
Seeley Dental Registration Form

Montana Cancer Screening Program Registration

Prefer to fill your registration form out by hand?
​Click here for a printable version (good at all sites)

Need to give us a quick update?
Click here to send us a copy of your photo ID
Click here to send us your insurance card(s)

Releases of Information (ROI)

Medical ROI
​Dental ROI

Prefer to fill your release form out by hand? 
Click here for a printable version of the medical ROI
Click here for a printable version of the dental ROI
​

Consents & Notices

Patient Rights and Responsibilities​
Notice of Privacy Practices
​​Parental Consent Form
​Verbal Communication Authorization
​Dental Services Agreement
​Certified Application Counselor (CAC) Consent

Financial Assistance

Missoula Sliding Fee Scale Application
Seeley Sliding Fee Scale Application

• Click here to send us a copy of your proof of income

Sliding Fee Scale discounts apply at all of our sites but
are processed at the clinic you visit most regularly.
Click here to learn more about the Sliding Fee Scale.

Payment Agreement Form (PDF)
Payment Agreement Form (fillable)

Pharmacy Payment Agreement Form (PDF)
Pharmacy Payment Agreement Form (fillable)