Forms – Plains Area Mental Health Center

After you’ve contacted the local office you’d like to visit, you’ll need to fill out the following forms. If you do not wish to download them, we are happy to mail them to your residence or you may fill them out at the office before your scheduled appointment.

New Patient Forms

Download and complete our patient forms before your first visit to make things easy and organized!

Notice of Privacy Practices

Informed Consent

Informed Consent Acknowledgment

Acknowledgment of Privacy Practices

Insurance Authorization

Authorization for Release of Information

Request to Review or Obtain Copies of Protected Health Information

Acknowledgement of Privacy Practices – Spanish

Informed Consent – Spanish

Informed Consent Acknowledgment – Spanish

Acknowledgment of Privacy Practices – Spanish

Insurance Authorization – Spanish

Authorization to Release Records – Spanish

Service Rates – Spanish

Patient Portal

Track your appointments, information and records through our secure patient portal.

Pay Bill

Secure online bill pay is available for your convenience.

Myanmar (Burmese)