You can submit your new patient forms ahead of your visit. This also enables kids under 18 to be seen at our school-based sites without an adult- you just need to submit a minor consent form! You can drop your signed forms off, or you can sign, scan, and either email the forms to our staff or drop them off at your clinic and give the signed forms to a front desk staff person. You can email to: outreachenrollment@promiseheath.org

Puede enviar sus formularios de paciente nuevo antes de su visita. Esto también permite que los niños menores de 18 años sean vistos en nuestros sitios escolares sin un adulto, ¡solo necesita enviar un formulario de consentimiento para menores! Puede dejar sus formularios firmados, o puede firmar, escanear y enviar los formularios por correo electrónico a nuestro personal o dejarlos en su clínica y entregar los formularios firmados a un miembro del personal de recepción. Puede enviar un correo electrónico a: outreachenrollment@promiseheath.org

Adult New Patient Forms/Formularios para Pacientes Nuevos Adultos

Promise Healthcare New Patient Form 2024

Promise Healthcare New Patient Form Rantoul 2024

Promise Healthcare New Patient Form 2024 Urbana

Promise Healthcare Nuevo Paquette de Paciente Urbana

Promise Healthcare Nuevo Paquette de Paciente Rantoul

Promise Healthcare Nuevo Paquette de Paciente

Minor New Patient Forms

Formularios para Pacientes Nuevos Menores

Promise Healthcare Minor New Patient Packet 2024

Promise Healthcare MINOR New Patient Packet Urbana

Promise Healthcare MINOR New Patient Packet Rantoul

Promise Healthcare Español-Menor-Nuevo-Paciente-Paquete

Promise Healthcare Español-Menor-Nuevo-Paciente-Paquete Urbana

Promise Healthcare Español-Menor-Nuevo-Paciente-Paquete Rantoul

Mental Health Wellness Referral Forms

MHW Referral English

MHW Referral Spanish

Consent Forms

Promise Minor Consent For Treatment Urbana

Promise Minor Consent For Treatment Champaign

Promise Minor Consent for Treatment Rantoul

Promise Minor Consent For Treatment

Promise Adult Consent For Treatment Champaign

Promise Adult Consent For Treatment Rantoul

Promise Adult Consent For Treatment Urbana

Medical Release of Information Forms

Authorize the Release of Protected Health Information

Autorizar la revelación de información

Autoriser la divulgation de renseignements protégés sur la santé

授权发布受保护的健康信息

Mental Health Release of Information Forms

Authorize the Release of Behavioral Health Information

Autorizar la revelación de información de salud conductual

Autoriser la divulgation derenseignements protégés sur la santé

授权发布行为健康信息

Request Medical Records

Patient Instructions for Medical Record Requests

HealthMark Group is a trusted provider that helps practices like ours manage the release of medical records. We chose to partner with HealthMark to streamline the process and get you your records faster and more efficiently.

How do I request my medical records?

Once you enter your email, you’ll receive an email with HealthMark to log in (no username or password required!). Click on the “submit request” button and follow the prompts from there. You’ll receive an email as soon as your records are available for download.

Do I have to remember another username and password?

Nope! HealthMark’s Request Manager uses email verification and secure links to get you your records quickly, efficiently and securely – and without yet another username and password to remember!

How long does it take to process requests?

Most record requests are processed within 8 business hours. So, one or two business days after you submit your request, your records will be delivered electronically – right to your inbox.

Any questions?

You can see the status of your request any time inside Request Manager. If you have any other questions, feel free to reach out to HealthMark at 800-659-4035 or status@healthmark-group.com.