WELCOME to NIMCHN

The Patient Packet

The Patient Packet contains the forms that we ask our patients to fill out during their first visit and once every year following. You’ll need Adobe Reader to view and complete these forms.  There is no need to print these form.  Just complete & hit submit. 

After hitting submit, you MUST LOG INTO YOUR EMAIL TO VERIFY before it will send to NIMCHN.

Medical Records Form

 If you would like us to release your records to another physician or if you have records from another medical practice that would be helpful to our providers please click on the link below to complete & submit a request for medical records. There is no need to print this form, just complete & hit submit.

After hitting submit, you MUST LOG INTO YOUR EMAIL TO VERIFY before it will send to NIMCHN.

Individual Forms

If you need to update your contact information or income please complete the Income Form below.

After hitting submit, you MUST LOG INTO YOUR EMAIL TO VERIFY before it will send to NIMCHN.

DIS Forms

These forms may be requested for you to fill out prior to meeting with one of our Disease Intervention Specialists.  You’ll need Adobe Reader to view and complete these forms.  There is no need to print these form.  Just complete & hit submit.