Free Community Feeding Thursday 9-25-25 10:30 AM-Little Flower Clinic Soup Kitchen

HOME
ABOUT US
LITTLE FLOWER STAFF
QUANTUM HEALTH STAFF
DONATE
COVID-19 GUIDE
PATIENT PORTAL
Gallery
Sliding Fee
Community Resources
PCMH
Project Bidding
More

Sign In
Create Account
Bookings
My Account

Signed in as:
filler@godaddy.com
Bookings
My Account
Sign out

Signed in as:

filler@godaddy.com

HOME
ABOUT US
LITTLE FLOWER STAFF
QUANTUM HEALTH STAFF
DONATE
COVID-19 GUIDE
PATIENT PORTAL
Gallery
Sliding Fee
Community Resources
PCMH
Project Bidding

Account

Bookings
My Account
Sign out

Sign In
Bookings
My Account

Kentucky Mountain Health Alliance, Inc.

Patient Portal Link

KMHA MEDICAL PATIENT SURVEY (docx)

KMHA DENTAL PATIENT SURVEY (docx)

Patient Registration Forms

** Please print and complete all forms and bring with you on your appointment date**

Housing Assessment (pdf)Download

Release and Permission (pdf)Download

Consent to Treat Adult (pdf)Download

Consent to Treat Minor (pdf)Download

HIPAA Consent Form (pdf)Download

Telemedicine Consent (pdf)Download

Patient Signature (pdf)Download

Patient Needs Updated 2025 (docx)Download

Other Policies and Forms

Patient Rights (pdf)Download

HIV and AIDS Information (pdf)Download

Privacy Practices (pdf)Download

Financial Policy (docx)Download

2025 SLIDING FEE DISCOUNT POLICY (docx)Download

ABN Form updated (docx)Download

Copyright © 2024, Kentucky Mountain Health Alliance, Inc. All Rights Reserved.

Powered by

This website uses cookies.

We use cookies to analyze website traffic and optimize your website experience. By accepting our use of cookies, your data will be aggregated with all other user data.