Patient Resources

Online Forms

Save time when you register as a new patient. You can fill them out in the comfort of your home and bring them with you to your appointment.

• Auto Accident form (PDF)
• Financial Assistance Application (PDF)
• DFMC Patient Health History Form 2023
• My Medication List (PDF)
• Patient Information & Authorization form (PDF)
• Parental / Guardian Consent to Treatment of a Minor (PDF)
• Release of Medical Information (PDF)
• Worker’s Compensation Claim (PDF)
• Authorization to Discuss your Health with Others (PDF)

What to Bring to Your Appointment

• Insurance cards
• Picture ID
• Medical records (You may be asked to sign a release of information to get old medical records.)
• Medication bottles or a list of your medications
• Guardianship papers (if you have them)
• Medical power of attorney information (if you have one)
• Advanced care directive (if you have one)

Billing Statements

We mail billing statements each month. Your statement will list:

• Services provided at your visit
• Charges submitted to your insurance company
• Payments we have received from the insurance company, if any

Patients Without Insurance

If you don’t have insurance, your account will be considered self-pay. If you pay for your medical services in full the day of your visit, you will get a 25% discount. If you’re having trouble making payments on your account, please consider filling out our financial assistance application.

Note: If you have previously been awarded financial assistance through Essentia Health or Aspirus St. Luke’s, you will still need to complete an application for Duluth Family Medicine Clinic.

Pay Online

• Pay your bill online as a MyChart guest. You will need the guarantor number from your bill.
• Pay your bill online as a MyChart member and log in.

Referrals

Your physician may decide you need to see a specialist for further testing or care. Please contact your health insurance company to verify whether specialty services are covered. If you have questions regarding referrals, call 218-723-1112.