Outpatient Forms

Outpatient Forms

 

The forms on this page are for patients of Pine Rest’s outpatient clinics only. If you have any questions, please call 866.852.4001.

New Patient Forms

Our new patient forms can now be completed online. Just select the state in which you are receiving services below. If you are receiving services through your Employee Assistance, Church Assistance or School Assistance Program, please use the forms that are labeled EAP on the corresponding tab for your state.

Please complete the appropriate form at least 24 hours before your first appointment.

If you do not have an appointment, please call 866.852.4001.

Michigan Online New Patient Forms

These forms are only for patients who are:

  • Receiving services at a Pine Rest outpatient clinic located in the state of Michigan
  • OR receiving Telehealth Services while located in the state of Michigan
If you are accessing services using your Pine Rest Employee Assistance (EAP), Church Assistance (CAP) or School Assistance (SAP) program, please use the EAP forms for your state.

Your Form should be completed and submitted at least 24 hours before your appointment.

The online form is quite comprehensive and could take approximately 30 minutes to complete. Please complete all forms to the best of your ability.

To start, click on the button below which lists the age of the person being treated. A new window will open asking you to set up an account so your form can be saved and completed later, if needed.

Michigan EAP Online New Patient Forms

Please use these forms if you are using your Pine Rest Employee Assistance Program, Church Assistance Program or Student Assistance Program to access services:

  • At a Pine Rest outpatient clinic located in the state of Michigan
  • OR through Telehealth Services while located in the state of Michigan

Your Form should be completed and submitted at least 24 hours before your appointment.

The online form is quite comprehensive and could take approximately 30 minutes to complete. Please complete all forms to the best of your ability.

To start, click on the button below which lists the age of the person being treated. A new window will open asking you to set up an account so your form can be saved and completed later, if needed.

IOWA ONLINE NEW PATIENT FORMS

These forms are only for patients who are:

  • Receiving services at the Pine Rest Pella Clinic located in the state of Iowa
  • OR receiving Telehealth Services while located in the state of Iowa
If you are accessing services using your Pine Rest Employee Assistance (EAP), Church Assistance (CAP) or School Assistance (SAP) program, please use the EAP forms for your state.

Your Form should be completed and submitted at least 24 hours before your appointment.

The online form is quite comprehensive and could take approximately 30 minutes to complete. Please complete all forms to the best of your ability.

To start, click on the button below which lists the age of the person being treated. A new window will open asking you to set up an account so your form can be saved and completed later, if needed.

Iowa EAP Online New Patient Forms

Please use these forms if you are using your Pine Rest Employee Assistance Program, Church Assistance Program or Student Assistance Program to access services:

  • At the Pine Rest Pella Clinic located in the state of Iowa
  • OR through Telehealth Services while located in the state of Iowa

Your Form should be completed and submitted at least 24 hours before your appointment.

The online form is quite comprehensive and could take approximately 30 minutes to complete. Please complete all forms to the best of your ability.

To start, click on the button below which lists the age of the person being treated. A new window will open asking you to set up an account so your form can be saved and completed later, if needed.

Printable New Client Forms for Outpatient Clinic Patients Only

If you are a Telehealth client, you must complete the online forms.


Please bring a completed New Client Form to your first visit if you do not complete the online form.

Print out the appropriate form for you, your child or your patient. The form must be completed in black or blue ink.

Child: Age 11 or under

Adolescent: Age 12 – 17

Adult: Age 18 and over

Release of Information Forms

In order to share your Protected Health Information (PHI), you will need to complete and sign a Release of Information form. Please complete the form for the state and/or clinic where your services are being provided.

PRINTABLE RELEASE OF INFORMATION FORMS

If you are a Telehealth client, you must complete the online forms.

If you are an Inpatient and Partial Hospitalization patients, you must use the HBS Release of Information form.


Please complete the form for the state and/or clinic where your services are being provided. A sample has also been supplied. Please complete in black or blue pen.

Michigan Release of Information Form – Telehealth Patients Only

If you are receiving your treatment in the clinic, you must complete the printed form.

If you are a Pine Rest INPATIENT or PARTIAL HOSPITALIZATION patient, please use the HBS Release of Information form.

Iowa Release of Information Form – Telehealth Patients Only

If you are receiving your treatment in the clinic, you must complete the printed form.

If you are a Pine Rest INPATIENT or PARTIAL HOSPITALIZATION patient, please use the HBS Release of Information form.

If you have questions, please call 866.852.4001.