Patient Documents & Forms
Sliding Fee Scale
Sliding Fee Scale - This document is the scale (based on income and family size) that is used to determine how much you will pay for your medical costs.
Sliding Fee Scale Quick Reference Guide - The Sliding Fee Scale Quick Reference Guide is an easy-to-understand guide on how the Sliding Fee Scale works. It is available in the following languages:
How Peoples Clinic Determines Your Sliding Fee Category - This reference can be helpful to understand how the Sliding Fee Scale works.
Annual Financial Assistance Application
Annual Financial Assistance Application (AFAA) - This form will need to be completed each year in order to qualify for help with your medical expensses. The form is available in the following languages:
Release of Information
As your primary health care provider, it is important for us to have access to all your healthcare records in order to provide you with the best quality of care.
Please print this Release of Information Form (ROI) linked above if you need a copy of your medical or dental records. This form must be completed, signed, and dated by the patient, parent, guardian, or legal representative. The request will not be honored if all fields are not completed. See some helpful tips on filling out the form by viewing our example.
If you have any questions regarding this form, call the Medical Records Department at 319-874-3409 to speak with a Health Information Representative.