Forms

For your convenience

We’ve collected the various forms and informational materials you may need when visiting our offices. If you have any questions or concerns, please contact us.

Please click on any of the links below to download a pdf copy of the forms to complete before your visit. The requested form will open in a new page, where you can print it or download it to your computer. If you do not have access to a printer, you can stop by your doctor’s office to pick up a copy, or plan on arriving for your appointment a few minutes early to take care of the paperwork.

Submitting forms can be easy as well, prior to your visit. Once filled out, either fax them to (812) 723-7989, or if you have a smart phone (with decent photo quality), take a picture of the form and send the image via email to: register@sichc.org. And in the email, please note your name and contact information in case we have any additional questions.

New Patient

• Sign Me Up for Follow My Health
• New Patient Registration Form
• HIPAA Form
• HIPPA Notice
• OB/Gyn First Visit
• OB/Gyn Follow-up

Wellness Visit

• Medicare Wellness
  • Men’s Preventive Wellness Plan
  • Women’s Preventive Wellness Plan
  • Medicare Health Risk Assessment (HRA)

Records

• Release of Medical Records

Physicals

• DOT Physical for Commercial Driver Medical Certification
  (Please note: CDL’s expire every 2 years. Please be sure yours is up to date!)
• Sports Physical Handout
  Please read before scheduling your child’s sports physical
• Sports Physical 
  To be filled out by parent or guardian prior to visit

Financial

• More Than Money Program
• Community Health Assistance Program (CHAP)

Assessments

• Connors Rating Scale (ADHD Assessment for Parents)
• Connors Rating Scale (ADHD Assessment for Teachers)

Advanced Directives

• Advanced Directives Brochure
  Before completing any of the forms in the following section, we recommend that you review this information about ways you can direct your medical care and treatment in the event that you are unable to communicate for yourself. You can find further information at Indiana State Department of Health’s Advanced  Directives Resource Center website.)
  • Appointment of Health Care Representative
  • Durable Power of Attorney
  • Physicians’ Orders for Scope of Treatment
  • Living Will
  • Life Prolonging Procedures Declaration
  • Do Not Resuscitate Order

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Orange County School Telehealth ONLINE Sign Up Forms

SignUp Page with Instructions and Telehealth program details

• HIPAA Form
• Telehealth Consent Form
• Telehealth Enrollment Form – Either under age 18 or over age 18, depending on student (or staff)
• CHAP Assistance Form
• Proof of Identity & Insurance Form

Orange County School Telehealth PRINT Sign Up Forms

• HIPAA Form
• Telehealth Consent Form
• Telehealth Enrollment Form (New Patient) – Pediatric (under 18yrs of Age)
• Telehealth Enrollment Form (New Patient) – Adult (over 18yrs of Age)
• CHAP Assistance Form
• Proof of Identity and Insurance Form