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BCC Forms

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Boundary Community Clinics Patient Forms

Completed forms can be emailed to [email protected] or Fax (208) 267-3757.

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[av_toggle title=’Authorization to Disclose Protected Health Information’ tags=” custom_id=” av_uid=’av-1xsvrx’]
Authorization to Disclose Protected Health Information
[av_toggle title=’Consent for Treatment’ tags=” custom_id=” av_uid=’av-e4t2e5′]
Consent for Treatment
[av_toggle title=’Health History Questionnaire’ tags=” custom_id=” av_uid=’av-cfef25′]
Health History Questionnaire
[av_toggle title=’Medical Information Release Form’ tags=” custom_id=” av_uid=’av-4l6ivx’]
Medical Information Release Form
[av_toggle title=’New Patient Information Packet’ tags=” custom_id=”]
New Patient Information Packet – All Forms
[av_toggle title=’No Show Policy’ tags=” custom_id=” av_uid=’av-9url1p’]
No Show Policy
[av_toggle title=’Patient Information Sheet’ tags=” custom_id=” av_uid=’av-2pbwd’]
Patient Information Sheet
[av_toggle title=’Portal Access Consent’ tags=” custom_id=” av_uid=’av-6l3wh9′]
Portal Access Consent and Agreement
[av_toggle title=’Prescription Policy’ tags=” custom_id=” av_uid=’av-4qaf99′]
Prescription Policy
[av_toggle title=’Request for Medical Records’ tags=” custom_id=” av_uid=’av-1wexxp’]
Request for Medical Records

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Need to schedule an appointment?
Call (208) 267-3655
Fax (208) 267-3757
Lucero Medical Services Building
6641 Kaniksu Street, Bonners Ferry, ID 83805

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