Patient Forms

Access patient forms below

Records Release
Form

Healthy Connections
Enrollment

Healthy Connections Enrollment (Spanish)

Special Circumstances Change Request Form

Special Circumstances Change Request Form (Spanish)

CALL 911 IF YOU THINK YOUR CHILD IS EXPERIENCING A LIFE-THREATENING EMERGENCY.

IF YOU THINK SOMEONE IS POISONED, CALL THE POISON CENTER AT 1-800-222-1222.

Idaho Falls

3320 So. 25th East

Idaho Falls, Idaho 83404

Phone: (208) 656-1500
Fax: (208) 656-1502

Chubbuck

190 Bullock St.
Chubbuck, ID 83202
Phone: (208) 992-5109
Fax: (208) 237-9029

Rexburg

1218 Bond Ave.
Rexburg, ID 83440
Phone: (208) 747-0339
Fax: (208) 900-4301

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