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Forms

Primary Care Clinics

New/Annual Patient Registration

Complete this form as a new patient. Expires twelve (12) months from the date signed and must be resubmitted annually.
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Form

Advance Directive

This form helps us understand who can help you make medical decisions if you should lose decision making capacity.
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Form

Patient Intake Checklist

Complete this form after completing the patient registration form.
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Form

Consent for Treatment of Minors & Release of Information

If the new patient is a minor, this form must be completed by a guardian.
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Form

Patient - Provider Agreement

This document outlines expectations between the patient and providers at Shalom Health Care Center.
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Document

Notice of Privacy Practices

This notice describes how your medical info may be used, disclosed, and accessed by you as the patient.
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Document

Patient Rights & Responsibilites

This document informs you about your rights to quality treatment, privacy, and participation in decisions and your responsibilities such as providing accurate information and adhering to prescribed treatments.
VIEW
Document

School-Based Clinic Forms

SBC Consent to Treat - English

This form must be completed before services can be provided to the student.
Complete Form
School

SBC Med Administration Consent - English

Complete this form if it becomes necessary for a student to take medication or receive treatment during the school day.
Complete Form
School

SBC Consent to Treat - Spanish

This form must be completed before services can be provided to the student.
Complete Form
School

SBC Med Administration Consent - Spanish

Complete this form if it becomes necessary for a student to take medication or receive treatment during the school day.
Complete Form
School

SBC Consent to Treat - Haitian Creole

This form must be completed before services can be provided to the student.
Complete Form
School

SBC Med Administration Consent - Spanish

Complete this form if it becomes necessary for a student to take medication or receive treatment during the school day.
Complete Form
School
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    OUR MISSION:

    TO PROVIDE QUALITY HEALTH CARE THAT IS PATIENT-CENTERED, AFFORDABLE AND ACCESSIBLE FOR ALL IN OUR COMMUNITY.

    The Shalom staff goes out of their way to accommodate our immediate needs and concerns.

    Tracie D.

    Shalom Patient

    HEALTH EQUITY FOR ALL IN OUR COMMUNITY

    Primary Care Clinic at 34th Street

    3400 Lafayette Road
    Suite 200
    Indianapolis, IN 46222
    (317) 291-7422

    Primary Care Clinic at 56th Street

    5750 W. 56th Street
    Indianapolis, IN 46254
    (317) 291-7422

    Primary Care Clinic at N. Meridian St.

    9240 N. Meridian Street
    Suite 180
    Indianapolis, IN 46260
    (317) 582-1100

    PATIENTS

    SUPPORTERS

    ABOUT SHALOM

    Shalom Health Care Center, Inc. receives federal funding from Department of Health and Human Services (HHS) 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.

    Shalom’s Primary Care Site(s) are supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H80CS00880 – Community Health Center Programs and 15% percentage financed with nongovernmental sources. This information is provided by Shalom Health care Center, Inc. It should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.”

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