Patient Forms

Print, download or complete forms online

We’re making waiting room paperwork a thing of the past. Prepare for a visit with your new WellSpan doctor, seek financial assistance, make plans for your care or access your private health record.

Follow the links below to our most-used health care forms and complete them when it’s convenient for you. Read, download and print what you need. You can even complete some forms online.

Health forms for adults

Below are some common forms you may need when you see a new WellSpan doctor. The doctor’s office may have additional forms for you to complete on your first visit.

New patient paperwork

This registration packet contains forms that must be completed, including your health history, permission to discuss protected health information and our financial policy and privacy notice.

New Patient Paperwork

Behavioral health new patient paperwork

This registration packet for behavioral health treatment specific to adult patients includes a health history and notices and consent forms.

Behavioral Health - Adults

Controlled substance agreement

You may need to complete this form if you’re prescribed certain medications whose use is controlled by state and federal laws.

Controlled substance agreement

Health forms for minors

Below are common forms that a parent or guardian may need to complete when your minor child sees a new WellSpan doctor.

New patient paperwork

This registration packet includes several forms that must be completed and signed by a parent or guardian on your child’s behalf.

New Patient Paperwork

Behavioral health new patient paperwork

This registration packet for behavioral health treatment specific to minor patients includes a health history, behavior assessments, notices and consent forms that must be completed and signed by a parent or guardian.

Behavioral Health - Children

Consent to treat

Parents or guardians use this form to grant a WellSpan doctor consent to treat their child.

Medical consent for minors

Controlled substance agreement

A parent or guardian may need to complete this form if your child is prescribed certain medications whose use is controlled by state and federal laws.

Controlled substance agreement

Medical record forms

Your secure MyWellSpan account is the fastest and easiest way to access your own medical record. Additionally, we offer the forms below to meet different needs. Find more information on our Medical Records page.

Authorization to Use or Disclose Health Information

This form can be used to request access to your medical record information or to share it with your doctor’s office. Requests can be made for your own record, or for someone for whom you are a legal representative.

21st Century Cures Act Request Form

Federal law supports seamless and secure access to electronic health information for you and your doctors. In accordance with the law, we offer this online form for requests to access, exchange or use health information.

Next of Kin Verification Form

Complete this form to verify that we can grant you access to medical records for a deceased loved one.

Patient Requested Amendment Form

Use this form to request changes to information in your medical record that you believe needs to be corrected.

Acknowledgement of Receipt of Privacy Practices

Complete this form after your have received and read our Privacy Practices.

Financial Policy and Consent for Treatment

This form outlines your consenting to treatment after understanding our financial policies and your responsibilities.

Other Forms and Resources

Financial assistance

 If financial hardship makes it difficult to pay your bills for WellSpan services, we offer options that could ease your financial burden.

Financial Assistance Forms

Prepare for the unexpected

Advance care planning

An unexpected crisis could prevent you from making your own medical decisions. Horizon Planning helps you explore, understand and choose your wishes for care and document those wishes with legal health care forms.

Create your Horizon Plan

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Patient Forms

Print, download or complete forms online

Authorization to Use or Disclose Health Information

21st Century Cures Act Request Form

Next of Kin Verification Form

Patient Requested Amendment Form

Acknowledgement of Receipt of Privacy Practices

Financial Policy and Consent for Treatment