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  • LaGrange Office - (260) 463-2133  |  Kendallville Office - (260) 347-5592
Northeast Internal MedicineNortheast Internal Medicine
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Online Forms

online forms

Following are a list of helpful forms for you to download and fill out ahead of your scheduled appointment.

New Patient Forms

New Patient form - online signup HIPAA Disclosure - ONLINE SIGNUP

Documents

Adult Medical History Form544.3 KBDisclosure of Protected Health Information280.4 KBFinancial Policy552.0 KBNarcotics Policy for New Patients199.0 KBPatient Information Form363.1 KBRelease of Medical Records Authorization320.4 KBPrivacy Policy3.4 MBNIMA Endoscopy Form87.5 KBColonoscopy Prep Form91.5 KB
NIMA

LaGrange Office:
(260) 463-2133

Kendallville Office:
(260) 347-5592

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Copyright 2022 © Northeast Internal Medicine Associates, P.C.
  • Home
  • About Us
    • Who We Are
    • News & Posts
  • Services
    • OUR SERVICES

      • X-Ray
      • EKG
      • Ultrasound
      • Laboratory Testing
      • Echocardiogram
      • Pulmonary Function Tests
      • Diabetic Teaching
      • Colonoscopy
      • EGD
    • PATIENT CARE

      • Nursing
      • Receptionist Corner
      • Online Forms
      • Diets
      • Resources
      • Monthly Awareness
      • MyChart
  • Providers
  • Billing
    • Billing Department
    • Online Payment
    • Participating Insurances
    • MyChart
  • Contact Us
    • Our Locations
    • Employment
    • MyChart
    • Privacy Policy
    • Customer Satisfaction Survey
  • Newsletter

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