Patient Information

NOTE: The links will open in a new window. You will see a tab on the right side of the screen to “Open PDF.” Once it is opened, in the right column, you will see a menu. Click “Fill & Sign.” Place the cursor on the first line and it will allow you to start typing your information. Continue the same throughout the document. When finished, save the document to you computer. Proceed to print the document, and either fax or send to address indicated below.

To request information from Compass Health Network:

Important Steps:

⦁ Determine what type of records you need to request. (Behavioral Health, Dental, Primary Care)
⦁ Complete all fields on the authorization form(s) when requesting the release of your records.
⦁ After the form(s) is signed and dated; deliver, fax or mail the information to an office listed below.

Behavioral Health
Request My Records: Access to Protected Health Information (PHI): English | en Español
Authorization of Disclosure of Protected Health Information: English | en Español

Primary Care and Dental
Request My Records: Access to Protected Health Information (PHI): English | en Español
Authorization of Disclosure of Protected Health Information: English | en Español

If there is information in Compass Health Network’s medical record about you that you believe is inaccurate or incomplete, you have the right to request the information be changed. Please complete the form and send it to the fax or address indicated below.

Request for Amendment of Personal Health Information: English | en Español

For questions regarding the above forms, please contact your local Health Information Management Office (Medical Records):

Compass Health Network – HIM Western Region
1800 Community Drive
Clinton, MO 64735
P: 660-890-8113 F: 660-890-8116
HIMClinton@Compasshn.org

Compass Health Network – HIM Eastern, Southern & Adapt Regions
1032 Crosswinds Court
Wentzville, MO 63385
P: 636-332-2104 F: 636-489-0651
HIMWentzville@Compasshn.org

Compass Health Network – HIM Central Region
1001 West Worley
Columbia, MO 65203
P: 573-214-2314 F: 573-814-2835
HIMWorley@Compasshn.org

Compass Health Network – HIM Jefferson County Region
227 East Main Street
Festus, MO 63028
P: 636-232-2318 F: 636-362-6609
HIMJeffCo@Compasshn.org

Compass Health Network – HIM Royal Oaks Hospital
307 North Main
Windsor, MO 65360
P: 660-647-2182 F: 660-647-2034
HIMROH@Compasshn.org

Notice of Privacy Practices

At Compass Health Network, we believe your health information is personal. We are committed to keeping your health information private, and we are required by law to respect your confidentiality. Our Notice of Privacy Practices describes the privacy practices of Compass Health Network.

Read Notice of Privacy Practices: English | en Español

Before your Appointment:

This checklist can help you prepare for your first visit at Compass Health Network.

Please bring these documents to your first visit:

Missouri Driver’s License or State Issues Photo ID
Proof of Missouri Residency
- Missouri Driver’s License OR Missouri ID
- Recent utility bill with client’s name with MO address
- Bank statement with client’s name and MO address
- Last year’s tax form
- Statement from a probation or parole officer.
Social Security number/card (at least need to be able to provide SSN)
Insurance Cards, including prescription cards when applicable.
Guardianship paperwork, if applicable
Proof of Income
- SSD, SSI gross amount before any deductions (current year award letter from SS)
- Last two consecutive paychecks (for both husband and wife if married), if employed
- Last Federal Tax Return
- Unemployment Compensation Letter stating current year benefits.
- Employer letter disclosing gross weekly or monthly pay
- Current year Pension or VA benefits
- No income at all will sign responsibility statement attesting that
Prescription Medications – please bring your prescription bottles with you or photos of any prescription medication labels you are taking.

Patient Packets

Compass Health Network Paperwork

Behavioral Health
New Patient Welcome Packet: English | en Español

Primary Care and Dental
Primary Care & Dental Welcome Packet: English | en Español

Dental & Primary Care Medical History (age 16 & over): English | en Español

Pediatric Dental & Primary Care Medical History (under age 16): English | en Español

Delegation of Another Person to Consent to Treatment for a Minor/Disabled Adult: English | en Español

You have the right to receive a “Good Faith Estimate”
explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have
insurance or who are not using insurance an estimate of the bill for medical
items and services (Visit our Sliding Fee page for more information).

You have the right to receive a Good Faith Estimate for the total
expected cost of any non-emergency items or services. This includes
related costs like medical tests, prescription drugs, equipment, and
hospital fees.
Make sure your health care provider gives you a Good Faith Estimate
in writing at least 1 business day before your medical service or item.
You can also ask your health care provider, and any other provider you
choose, for a Good Faith Estimate before you schedule an item or
service.
If you receive a bill that is at least $400 more than your Good Faith
Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate,
visit www.cms.gov/nosurprises or call 844-853-8937 (Toll Free)

IMPORTANT: Scroll left to view all four (4) tabs

Patient Information

UPDATE FOR MONDAY – JANUARY 6, 2025