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This form authorizes Essential Health Clinic to access medical information or records held by another healthcare provider.
This form authorizes Essential Health Clinic to release medical information or records to another healthcare provider.
This form may be required if you are enrolling in the Wisconsin Family Planning Only Services (FPOS) assistance program. To enroll in FPOS you will need either a month of your most recent pay stubs OR an Employment Verification Form for all jobs you have held in the last three months.
You may be eligible for the Family Planning Only Services (FPOS) assistance program to help cover the cost of your visit. This brochure contains more information about FPOS, including eligibility requirements.
This form is required if you are receiving your birth control pills in the mail. In order to be eligible for mail order resupply, you must already be a client of Essential Health Clinic, and you must have a current birth control prescription from Essential Health Clinic.
You can always access our Notice of Privacy Practices on our website, or obtain a copy at any Essential Health Clinic location.