Primary Care Forms and Policies

The following forms and policies may be helpful to review and/or fill out prior to your next appointment.

FORMS

Minor Consent Forms

Prairie Lakes Brown Clinic is required to protect the rights of our patients and ensure the safety of minors. Any new patient under the age of 18 must be seen in the presence of their parent and/or legal guardian. It is important that the parent/legal guardian is aware of the minor's condition or conditions, and everyone understands and follows through with the recommended treatment plan. Parents and/or legal guardians will be asked to provide identification via a valid photo ID.

An established patient (a patient known to the practice and seen within the past 12 months) under the age of 18 may be brought in for a specific visit or timeframe by a non-custodial adult if written permission is given by the parent or legal guardian, and that adult shows a valid photo ID. The parent or legal guardian must leave a number where they can be reached on the date of service.

A signed and witnessed consent form from the parent/legal guardian may be signed prior to the visit, allowing the minor patient to be seen without the parent/legal guardian present.

There are certain types of minors authorized to consent because of their status. Some examples are, but not limited to, married minors, minors on active duty with the U.S. Armed Forces, and minors emancipated by a court order.

• pdf Minor Consent Form (101 KB)
• pdf Minor Consent Form (Spanish) (99 KB)
• pdf Parent-Guardian Medical Consent for a Minor (208 KB)

Patient Forms

• pdf Patient Information (82 KB)
• pdf New Patient Packet (1.27 MB)
• pdf Health History Profile (486 KB)
• pdf Authorization for Disclosure of Health Information (86 KB)
• pdf Form Completion Request (85 KB)
• pdf Screening Checklist for Contraindications to Vaccines for Children and Teen (175 KB)
• pdf Proxy Patient Portal Consent Form (73 KB)
• pdf Request for Disclosure of PHI to Family Members (57 KB)
• pdf Prairie Lakes Brown Clinic Providers, Services, and Hours (1.14 MB)

NOTE: Firefox users will need to download the forms or open them in a PDF reader to enter the fields. For more information visit https://support.mozilla.org/en-US/kb/disable-built-pdf-viewer-and-use-another-viewer

Sports Physical Parent/Guardian Permit & History Forms

All high school athletes need to schedule a sports physical with their provider. Prior to the exam, the forms must be completed and signed by the student's guardian.

Print Instructions:

1. Download the  pdf South Dakota High School Activities Association Pre-Participation Form Packet (565 KB)
2. Print the forms.
3. Fill out the forms.
4. Bring the completed signed forms to your appointment.

POLICIES

Financial Policy

Prairie Lakes Brown Clinic is committed to providing you with the best possible medical care; if you have special needs, we are here to work with you. The following information is provided to avoid any misunderstanding or disagreement concerning payment for professional services.

• The total patient balance due, including any co-payment or co-insurance, is required to be paid at the time services are provided. For your convenience, we accept cash, checks, Visa, MasterCard, Discover and American Express.
• Our office participates with a variety of insurance plans. It is your responsibility to:
  • Bring your insurance card to every visit.
  • Be prepared to pay your co-payment at each visit. Payment can be made by cash, check,or credit card.
  • For medical care not covered under insurance, the estimated payment in full is due at the time of the visit.
• If you are unable to pay for necessary medical care, you may be eligible to participate in a payment plan. It is your responsibility to inform us of this prior to your visit. We will be pleased to refer you to a Prairie Lakes Brown Clinic Financial Counselor prior to scheduling you for a visit.
• Referrals: It is your responsibility to bring any required referrals for treatment at, or prior to the visit. If you do not have the referral, your visit may be rescheduled or you may be held financially responsible.
• If the patient is a minor (younger than 18 years) and is unaccompanied by a parent or guardian, we must have a written release/permission from the parent or guardian. The parent, guardian or unaccompanied minor is responsible for any payment due at the time of service, bringing the necessary referrals and the insurance card.
• If you have questions about your insurance, we are happy to help you. Specific coverage issues, however, should be directed to your insurance company member services department (number is on the insurance card).

Prairie Lakes Brown Clinic firmly believes that a good patient/physician relationship is based upon understanding and good communications. Questions about financial arrangements should be asked prior to services provided.

HIPPA Notice of Privacy Practices

The HIPAA Privacy Rule requires health plans and covered health care providers to develop and distribute a notice that provides a clear, user friendly explanation of individuals rights with respect to their personal health information and the privacy practices of health plans and health care providers. View Prairie Lakes Healthcare System's  pdf Notice of Privacy Practices (228 KB) .

Health Insurance Marketplace Coverage

The health insurance Marketplace is available to assist you as you evaluate options for you and your family. Review our pdf Health Insurance Marketplace Coverage Information (110 KB) .