Our next Free Community Feeding is Thursday, 10/22/26, 11 AM

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HOME
ABOUT US
LITTLE FLOWER STAFF
QUANTUM HEALTH STAFF
EYE CARE CENTER
PATIENT PORTAL
Sliding Fee
Community Resources
PCMH
COVID-19 GUIDE
Gallery
The Soup Kitchen
DONATE
Project Bidding
NOTICE OF DATA BREECH

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Bookings
My Account
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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.

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