Forms and Instructions

for Multicare Associated Clinics
Multicare Associates offers the following forms and instructions.


Records Release Form


There comes a time when nearly every patient needs a copy of their medical records or needs documentation of specific health information contained in their record. Because patient information is private and confidential, a valid authorization must be obtained. Multicare has a team of individuals solely focused on maintaining, storing and releasing patient information.

Fridley Medical Center - Fax: (763) 785-3329
Blaine Medical Center - Fax: (763) 785-8424
Roseville Medical Center - Fax: (763) 785-7716

More Information and Instructions | Records Release Form



Durable Power of Attorney for Healthcare Decisions

It is important to choose someone to make healthcare decisions for you when you cannot make or communicate decisions for yourself.
Take a copy of this form whenever you go to the hospital or on a trip.
Durable Power of Attorney for Healthcare Decisions


Authorization to Discuss Protected Health Information

You may use this form to allow your healthcare providers to disclose, access, and use your health information from services provided.
Authorization to Discuss Protected Health Information Form


Occupational Health
Download the Employer Authorization for Care form



Patient Portal

Patient Portal Registration form



General Information


Tips for Any Appointment - This paper provides you with a check list of information that you may want to discuss with your Health Care Provider. Print Communicate with Your Health Care Provider, write reminders on it, and bring it with you to your appointment.
Communicate with your Provider

Charges and How They Relate to Preventive and Problem-Oriented Visits - This paper discusses insurance coverage and how portions of an office visit can be interpreted differently for reimbursement purposes.
Important Facts for our Patients Regarding Preventive and Problem-Oriented Services Given In the Same Visit

Tests and Examinations - is a chart that shows what you might expect when you see your health care provider.
Test and Examination Expectations


Female Exam Form
- Download Female Preventative Physical Exam Form
Female Preventative Physical Exam Form


Male Exam Form
- Download Male Preventative Physical Exam Form
Male Preventative Physical Exam Form



Appointment Prep Instructions

Adult Physical Exam - For information regarding your adult physical exam and preparations for the visit, read and/or print Adult Physical Exam Instructions. If you have scheduled a blood draw for cholesterol or diabetes - prepare by following the instructions in Patient Preparatory Instructions Fasting Blood Work.

Adult Physical Exam Instructions | Patient Preparatory Instructions Fasting Blood Work


Assessment Forms


*Assessments / Questionnaires will not be evaluated without an appointment

ADHD / ADD Assessment - If the doctor is assessing the patient for ADHD or ADD and you are the parent, please print and complete the History form for ADHD Assessment. This form needs to be filled out before arriving at the clinic for the appointment.

History form for ADHD Assessment

ADHD / ADD Assessment - If the doctor is assessing the patient for ADHD or ADD and you are the parent, please print and complete the NICHQ Vanderbilt Assessment Scale (Parent). This form needs to be filled out before arriving at the clinic for the appointment.

NICHQ Vanderbilt Assessment Scale (Parent)

ADHD / ADD Assessment - If the doctor is assessing the patient for ADHD or ADD and you are the patient's teacher, please print and complete the NICHQ Vanderbilt Assessment Scale (Teacher). This form needs to be filled and mailed to the clinic as quickly as possible.

NICHQ Vanderbilt Assessment Scale (Teacher)

Kindergarten/Pre-school medical examination form is for children ages four and older when they are entering the school system. Please print the Kindergarten Physical Questionnaire, complete it, and bring it with you to the appointment.

Kindergarten Physical Questionnaire

*Pediatric Symptom Checklist (PSC) Ages 6-10

*Pediatric Symptom Checklist Youth Report (Y-PSC) Ages 11-18


3-hour Glucose Tolerance Test - follow these instructions if you are having this lab test.

3-hour Glucose Tolerance Test Instructions

Glucose Testing - for the types of regular glucose testing: standard, two-hour post prandial, glucose tolerance test, one-hour glucose test for OB patients, two-, three-, and five-hour glucose test (for all patients); please follow the instructions in Glucose Testing.

Glucose Testing Instructions

New Patients With Our Dietician - when an appointment for a new consult is scheduled with our dietician. Print the form now, complete it, and bring it with you to the appointment.

New Dietician Patient Food Diary