Patient Forms and Sliding Fee Scale
Interested in becoming a valued patient at PureView? Give us a call now at 406-457-0000 and let us guide you towards exceptional healthcare.
Can't wait for an appointment? PureView offers walk-in appointments every morning to new or established patients at our two Helena locations.
Please arrive 15 minutes before your scheduled appointment and bring:
- Insurance card
- List of medications you regularly take
- Immunization record
- Appropriate income support documentation if you want to apply for the Sliding Fee Discount Program. Please see the Sliding Fee Discount Program application for a detailed list of approved documentation.
We offer convenient online access to our new patient forms to make your first visit to PureView Health Center as smooth and efficient as possible. Click the appropriate button to access our forms in the Portable Document Format (PDF), which requires Adobe’s Acrobat Reader.
Once you have accessed the forms, you can print them out, fill them in, and bring them when you come for your appointment. This way, you can save time and avoid unnecessary delays in receiving the necessary medical care.
- Patient Information – PureView Health Center (PDF Version)
- MEDICAL RECORDS RELEASE OF INFORMATION (PDF Version)
- GENERAL AUTHORIZATION FOR TREATMENT (PDF VERSION)
- HCH Enrollment Form (PDF Version)
- Affidavit of Financial Status (PDF Version)
- Welcome Brochure 2023 / PCMH Information (PDF Version)
Sliding Fee Schedule Information and Application
As a Federally Qualified Health Center, PureView Health Center is committed to providing affordable healthcare to all individuals. Our sliding fee scale is designed to assist patients who have concerns about the affordability of care.
Depending on your family income and size, you may be eligible for our Sliding Fee Discount Program. Our goal is to ensure everyone in our community can access quality healthcare, regardless of their financial situation. So don't let the cost of medical care be a barrier to your health. Contact PureView Health Center today to learn more about our Sliding Fee Discount Program.
- Sliding Fee Discount Program Application (PDF Version)
What Will I Pay?
At PureView, everyone deserves access to quality healthcare, regardless of their financial situation. We offer a sliding fee schedule based on federal income guidelines.
If you meet these guidelines and provide proof of income, you're eligible for our Sliding Fee Discount Program, regardless of your insurance status. Our sliding fee scales consider your income and family size, ensuring you get the care you need without breaking the bank.
PATIENT BILL OF RIGHTS
Before receiving treatment, you have the RIGHT to:
- Receive written information about your rights and responsibilities.
- Request information about policies, procedures, services and charges.
- Know payment policies and your payment responsibilities.
- Know the name and title of everyone providing services to you.
- Choose your provider. Know the governing agencies of the PureView Health Center.
As a patient, you have the RIGHT to:
- Receive fair, considerate, respectful, and quality care.
- Information about your diagnosis and treatment options.
- Participate in making decisions about your treatment plan.
- Accept or refuse treatment and be informed of the consequences.
- Receive clinically approved treatment to alleviate pain when the treatment is appropriate, necessary, and meets your health care needs.
- Privacy of personal information and confidential treatment.
- Have access or a copy of your records by making a written request.
- Make written or verbal complaints to the Executive Director.
- Recommend changes or make complaints without repercussions.
- Know our procedures for living wills and advance directives.
As a patient, you have the RESPONSIBILITY to:
- Show respect for other patients and health care workers.
- Work cooperatively with staff and carry out agreed-upon treatment.
- Ask questions if you disagree or do not understand your treatment.
- Recognize the limits of science and medical technology.
- Always provide complete, honest, updated health information.
- Cancel or reschedule when you are unable to keep an appointment.
- Provide proof of insurance and/or income, initially and as requested.