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Kentucky Mountain Health Alliance, Inc.
Patient Portal Link

KMHA MEDICAL PATIENT SURVEY (docx)

Download

KMHA DENTAL PATIENT SURVEY (docx)

Download

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 Assessment updated (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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