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Your Forms

Below Are Your Available Forms

New/Existing Patient Screenings & Information:

PHQ-9 Patient Health Questionnaire (Well Woman/Man Exams)
Well Woman Exam Questionnaire
Well Male Exam Questionnaire
Vanderbilt Assessment for Parents
Vanderbilt Assessment for Teachers
Sleep Log for Dr. Wills Sleep Consultations
Minnesota High School Sports Physical Form

General Forms:

Medical Records Release to NKH from Another Facility
Medical Records Release from NKH to Another Facility
Consent to Treat Minor Children
Consent to Grant Individual(s) Access to Protected Health Information
Health Care Summary (Must be completed by Health Source)
Document Granting PHI Information

Other:

Release, Consent, and HIPPA (All in one form)
HIPPA
Release and Consent
Privacy Statement

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Employment Application

Fill Out the Form Below!

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Are you over the age of 18?(Required)

Yes

No

Are you legally allowed to work in the U.S.?(Required)

Yes

No

Position for which you are applying(Required)

Desired Hourly Wage(Required)

Desired type of employment(Required)

Full-time

Part-time

On-call

Are you able to work weekends?(Required)

Yes

No

Highest level of education received(Required)

High School

Associate

Bachelor

Masters

Doctorate

Name of School(Required)

Year graduated(Required)

Last employer(Required)

Dates worked for employer(Required)

Job title(Required)

Description of your role and key accomplishments(Required)

Attach Resume(Required)

Max. file size: 1 GB.

Upload your resume here

Request Employment Verification

Fill out the form below

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Your Name

Please Describe the Information Requested

Please Upload the Form Provided by Requester (If Applicable)

Click or drag a file to this area to upload.

Phone

Address Change

Change your address by filling out the form below:

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Name *

New Address *

Address Line 1

Address Line 2

City

State

Zip Code

Website

Personal Info and w-4 Upload

Company Holidays (Office Closed)

New Years Day
Easter
Memorial Day
Independence Day
Labor Day
Thanksgiving
Christmas Day

$250 Employee Healthcare Benefit

For information regarding your $250 EE healthcare benefit and how to use, please contact Emily Walters who will assist you through the process. [email protected]

W-4 Forms

If you need to download and print the W-4 forms, please click here to view and print.

https://www.irs.gov/pub/irs-pdf/fw4.pdf

https://www.revenue.state.mn.us/sites/default/files/2022-01/w-4mn.pdf

If you have filled out both your Federal and Minnesota W-4 form and are ready to submit, please attach the form now.

Update your W-4 by filling out the form below:

Please enable JavaScript in your browser to complete this form.

Employee Name

Upload Your Completed W-4 Form(s)

Click or drag a file to this area to upload.

Message

InterPreter Request

Please Give Two Weeks Notice For Interpreter Request

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Your Name *

Patient Name *

Patient Date of Birth *

Provider *

Visit Type *

Location for Interpreter *

Date / Time the Interpreter is Needed *

Date

Time

Language Required

Email

401K Enrollment Form

Please complete the employee sections of the enrollment form found at this link. Click here.

Once you have completed the form, please attach and submit for processing. You will be notified once your account is setup.

Here are some things to keep in mind:

Plan Description
Fee Disclosure
Account Access

Please enable JavaScript in your browser to complete this form.

Upload Your Completed Enrollment Form

Click or drag a file to this area to upload.

Comment

Direct Deposit

Use this form to setup or update your Direct Deposit information. Contact Karissa at [email protected] with any questions.

Please enable JavaScript in your browser to complete this form.

Employee Name

Account 1 Name

Name of Financial Institution

Account Type

Checking
Savings

Routing Number (ABA Number)

Account Number

Percentage or Dollar Amount to be Deposited to this Account

Upload a Blank Check or Deposit Slip

Click or drag a file to this area to upload.

Account 2 Name (Remainder to be Deposited to this Account)

Name of Financial Institution

Account 2 Type

Checking
Savings

Routing Number (ABA Number)

Account Number

Upload a Blank Check or Deposit Slip

Click or drag a file to this area to upload.

Phone

Submit W-4 Info

W-4 Forms

If you need to download and print the W-4 forms, please click here to view and print.

https://www.irs.gov/pub/irs-pdf/fw4.pdf

https://www.revenue.state.mn.us/sites/default/files/2022-01/w-4mn.pdf

If you have filled out both your Federal and Minnesota W-4 form and are ready to submit, please attach the form now.

Please enable JavaScript in your browser to complete this form.

Employee Name

Upload Your Completed W-4 Form(s)

Click or drag a file to this area to upload.

Phone

Payroll Setup Form

Please enable JavaScript in your browser to complete this form.

Name *

Dropdown

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Social Security Number

Marital Status

Date of Birth

Date of Hire

Department

Wage

Phone

New Hire Request Form

Use this form to make a new hire request. If you have any questions, please contact [email protected].

Please enable JavaScript in your browser to complete this form.

Your Name *

Hiring for Which Location *

Hiring Department *

Hiring for What Position (Job Title)

What Degree is Required

Employment Status

Days & Hours Needed to Work

Desired Start Date

Job Description

Please Upload Copy of Job Description

Click or drag a file to this area to upload.

Website

Legal

Please describe the situation and submit for Jeffrey to review. If you have questions, please contact Jeffrey at [email protected]

Patient Complaints

Please provide the following information and we will follow up on the complaint. If you have any questions, please contact Karissa Lucas at [email protected]

Technical Support Ticket

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Name *

Email *

Phone

Issue / Request Type

PC/Laptop/Computer
Network/Internet
Phone
Email
Equipment Request

Please Describe Your Issue / Request

Message

Lab Supply Order

Please complete the following information to have your lab supply order processed. If you have any questions, please contact Shelly at [email protected]

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Name

Location for Lab Supply Delivery

Item Name

Item Number

Quantity Needed

Item Description

Please Upload Photo (If New Item)

Click or drag a file to this area to upload.

Message

Supply Order Request

Please use this form to place a supply order request. Contact Sara at [email protected] with any questions.

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Name *

Location for Supply Delivery *

Department *

Item Name

Item Number

Quantity Needed

Item Description

Please Upload Photo (If New Item)

Click or drag a file to this area to upload.

Name

Maintenance Request

Please provide the following information and Jeffrey will be in touch with you shortly regarding your request.

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Name *

Location for Maintenance *

Describe the Maintenance Needed

Please Upload Photo (If Helpful)

Click or drag a file to this area to upload.

Message

Fill Out Your Records Request Below

Fill in all relevant info below and someone from our office will be in touch with you.

Name(Required)

First Last

Email(Required)

Phone(Required)

What records are you requesting?(Required)

File Upload(Required)

Max. file size: 1 GB.

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Fill Out Your Form Request Below

Fill in all relevant info below and someone from our office will be in touch with you.

Name(Required)

First Last

Email(Required)

Phone(Required)

What form are you requesting?(Required)

File Upload(Required)

Max. file size: 1 GB.

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Fill Out Your Billing Request Below

Fill in all relevant info below and someone from our office will be in touch with you.

Name(Required)

First Last

Email(Required)

Phone(Required)

How can we help you with billing?(Required)

File Upload

Max. file size: 1 GB.

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