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Partnership Health Center
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Forms

Missoula Creamery Clinic Building

Forms

 Our most frequently used forms can be found on this page. Please contact us if you have questions.

Registration

Missoula Medical & BH Registration Form
Missoula Dental Registration Form

Seeley Medical & BH Registration Form
Seeley Dental Registration Form

Superior BH Registration Form
Superior Dental Registration Form

Montana Cancer Screening Program Registration

Prefer to fill your registration form out by hand?
​
Click here for a printable version (good at all sites)

Need to give us a quick update?
Click here to send us a copy of your photo ID
Click here to send us your insurance card(s)

Releases of Information (ROI)

Medical ROI
​Dental ROI

Prefer to fill your release form out by hand? 
Click here for a printable version of the medical ROI
Click here for a printable version of the dental ROI
​

Consents & Notices

Notice of Privacy Practices
​​Parental Consent Form
​Verbal Communication Authorization
​Dental Services Agreement
​
Certified Application Counselor (CAC) Consent

Financial Assistance

Missoula Sliding Fee Scale Application
Seeley Sliding Fee Scale Application
Superior Sliding Fee Scale Application
Sliding Fee Scale discounts apply at all of our sites but
are processed at the clinic you visit most regularly.

Click here to learn more about the Sliding Fee Scale.


Payment Agreement Form (PDF)
Payment Agreement Form (fillable)

Pharmacy Payment Agreement Form (PDF)
Pharmacy Payment Agreement Form (fillable)
​
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Logo of Partnership Health Center-- Missoula's Community Health Center
401 Railroad St. W 
Missoula, MT 59802

​Main Line: (406) 258-4789
​
Dental: (406) 258-4185
Behavioral Health: (406) 258-4497
Pharmacy: (406) 258-4139
Billing: (406) 258-4195
Fax: (406) 258-4732

View hours at all our locations here.

Tell Us About Your Experience

This is not a secure form of communication. It is not HIPAA compliant and therefore should not be used to send personal health information. If you have a question for your provider please call PHC at (406-258-4789) or use the secure web Patient Portal.
Send Message

Find Us

We are conveniently located in downtown Missoula at 401 Railroad St. W. We are easily accessed from I-90 via the Orange Street Exit. PHC is also just blocks away from the Mountain Line Transfer Station, also located downtown.
This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.
 NOTICE OF NONDISCRIMINATION: 
Partnership Health Center does not discriminate against any person on the basis of race, color, national origin, disability, age, or sex (gender) in admission, or access to, or treatment, or employment in, its programs, services, or activities.  
Read the Full Notice:  Partnership Health Center Notice of Nondiscrimination
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LIMITED ENGLISH PROFICIENCY ASSISTANCE: 
Partnership Health Center
provides language assistance services, including translated documents and oral interpretation, to individuals with limited English proficiency. We provide assistance in the following languages:
Español  |  Tiếng Việt  |  繁體中文  |  한국어  |  Русский  |  العربية  |  Deutsch  |  Français  |  Tagalog  | ภาษาไทย  |  Norsk  |  Українська  |  Deitsch  |  Italiano  |  日本語 

Partnership Health Center respectfully acknowledges that we are guests on the traditional territories of the Séliš (Salish) and QÌispé (upper Kalispel or Pend d’Oreille) Peoples. We recognize those Native communities in our region today, and we extend gratitude to those who have stewarded this land for generations.

  • Services
    • Medical
    • Dental
    • Behavioral Health >
      • Self-Care Resources
    • Pharmacy
    • Telehealth
    • Additional Services >
      • Montana Cancer Screening Program
    • Financial Assistance
  • New Patients
  • Forms
  • About
    • Welcome
    • History
    • Who We Are
    • Our Providers
    • Locations & Hours
    • Careers
    • Education and Training
  • News and Events
    • Public Meetings
    • Events and Announcements
    • PHC in the News
    • COVID-19 Updates
  • Support PHC
    • Donate
    • Volunteer
    • PHC Shop