New Patient Packet 2025

Welcome to the Tuolumne Me-Wuk Indian Health Center!

Our Mission: Is to provide high quality, comprehensive, primary and specialty healthcare for the
Tuolumne Me-Wuk Tribal members, other Native Americans, and residents of the surrounding communities.

Our Vision: To be the leader of Sovereign Nations in caring for our communities by achieving and promoting
excellence in healthcare and wellness.

Checklist for all new patients:

Photo ID
Insurance card
Medications
New patient paperwork
Immunization record

Minors need to additionally bring:

Photo ID if available
Court documents identifying parental rights/custodian if applicable
Treatment consent form

Locations

Primary Care

Services: Routine Office Visits, Women’s Health, Family Care, Pediatric Care, Diabetic Treatment, Smoking Cessation Treatment, and Lab Drawing & Interpretation. (**referral required for outside lab draw)

Tuolumne Primary Care 18880 Cherry Valley BLVD, Tuolumne, CA 95379 Phone: 209-928-5400
Sonora Primary Care 22044 Cedar Road. Sonora, CA 95370 Phone: 209-928-5400

Behavioral Health\ Counseling

Services: Our patient-centered approach to therapy combines holistic practices, Hand-tailored Psychotherapy, and Medication management, Depression, Bipolar Disorder, Anxiety, Panic Disorder, Obsessive-Compulsive Disorder, Body Dysmorphia, Trauma/PTSD, Grief

Tuolumne Behavioral Health 18880 Cherry Valley BLVD, Tuolumne, CA 95379 Phone: 209-928-5400
Sonora Behavioral Health 19969 Greenley Road, Suite A, Sonora, CA 95370 Phone: 209-928-5400
Mariposa Behavioral Health 5078 Bullion Street, Suite 4, Mariposa, CA. 95338 Phone: 209-928-5400

Podiatry

Services: General Foot Care, Treatment Of Foot and Ankle injuries, Diabetic foot care, Custom
Orthotics, Treatment for bunions, Hammertoes, and Other Foot Deformities, Ingrown Toenail TX
22044 Cedar Road. Sonora, CA 95370 Phone: 209-928-5400

MeWu:Ya “The Family Healing Place’”

Services: Medication Assisted Treatment for Substance Use Disorder, Substance Use Disorder
Counseling, One-on-one Counseling, Group Counseling, Native Circle 12 Step Recovery Program,
Community Outreach
18670 Carter Street, Tuolumne, CA 95379 Phone: 209-928-5400

Dental Clinic

Services: Examinations, Cleanings, Fluoride treatments, Sealants, Nutritional Counseling, Fillings,
Crowns, Prosthetics, Full and Partial Dentures, Bridgework
19969 Greenley Road, Suite D Sonora, CA 95370 Phone: 209-928-5400

Optometry

Services: Comprehensive Eye Exams, Intermediate Eye Exams (without dilation), IOP checks, Glaucoma
Checks, Diabetic Eye exams, Contact Lens Evaluations, Cataract Evaluations, and Post-Operative Care for
Cataract Surgery and Refractive Surgery.
14550 Mono Way, Sonora, CA. 95370 Phone: 209-206-4820

Physical Therapy

Services: Back and neck pain, Body Misalignments/scoliosis/spinal dysfunctions, Chronic
Pain/Fibromyalgia, Muscle, Myofascial and Joint pain, Pre and Post-Operative conditions
850 Sanguinetti Rd, Sonora, CA 95370 Phone: 209-694-3870

Application Type(Required)

New Application

Re-Establish

Update

Services of Interest(Required)

Patient Last Name:(Required)

First Name:(Required)

Middle Name:(Required)

Preferred Name:

DOB:(Required)

Marital Status:

Social Security # (SSN):(Required)

Gender at Birth:(Required)

Race:

Veteran:(Required)

Yes

Branch of Service:

Preferred Language:(Required)

Religion:

Advance Directive:(Required)

Yes

Home Phone:

Cell Phone:

Email Address:(Required)

Mailing Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is your physical address different from your mailing address?(Required)

Yes

Physical Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contact:

Emergency Contact Name:

Relationship:

Emergency Contact Phone:

Tribal Information (If applicable):

Notice of PRC Eligibility Requirement: Eligibility for Indian Health Services (IHS)/Purchased Referred Care (PRC) services are contingent upon the receipt and verification of required documentation by the PRC Department. No services will be authorized or covered under IHS/PRC until eligibility has been confirmed. Patients may be held financially responsible for services rendered prior to verification.

Tribal Affiliation:

Tribal Address (City & State):

Tribal Roll Number:

Guarantor Information

Guarantor Information / Parent / Guardian:

* Guarantor is the individual or entity financially responsible for a patient's medical bills.
* Please provide court documentation if guarantor is other than responsible party.

Name(Required)

First Last

Relationship(Required)

Date of Birth(Required)

Phone(Required)

Insurance Information:

Primary Insurance:

Policy ID #:

Name of Policy Holder (Primary):

DOB:

Group #:

Secondary Insurance:

Policy ID#:

Name of Policy Holder (Secondary):

DOB:

Group #:

Dental Insurance:

Policy ID#:

Name of Policy Holder (Dental):

DOB:

Group #:

Vision Insurance:

Policy ID #

Name of Policy Holder (Vision):

DOB:

Group #:

Prescription Coverage:

Policy ID #:

Name of Policy Holder (Prescription):

DOB:

Group #:

ID & Insurance Card

Please take a picture of you driver’s license and insurance card to upload. You must also bring both on the day of your appointment.

ID & Insurance Card Upload(Required)

Drop files here or

Accepted file types: jpg, gif, png, pdf, bmp, jpeg, tif, webp, Max. file size: 25 MB, Max. files: 6.

AUTHORIZATION TO RELEASE INFORMATION FOR BILLING PURPOSES AND PAYMENT OF BENEFITS TO TMWIHC:
I hereby authorize the release of any information including diagnosis of a medical condition for the sole purpose of submission to Third Party billing insurance carriers, and that the statements above are true and correct to the best of my knowledge. I understand that if all insurance information is not complete or correct, I may be responsible for services rendered. I further authorize payment of all service benefits to TMWIHC.

Authorization to Release Information:(Required)

By checking the box below, you consent to the release of information for billing purposes and the payment of benefits to TMWIHC. Your signature at the bottom of this form confirms your acknowledgment of this authorization and all other information provided in the form.

Yes

Patient Information:

Please list the names and contact information of other practitioners you have or are currently seeing:

Medical Provider:

Mental Health Provider:

Dentist:

Preferred Pharmacy:

Secondary pharmacy / Mail order:

Medication List:

Please list all prescription and non-prescription medications. This includes vitamins, herbal medicine, supplements, birth control pills, inhalers and over the counter medications.

Medication - 1

Dosage & How Often - 1

Disease or Reason - 1

Do you have additional medication to add? (2)(Required)

Yes

Medication - 2

Dosage & How Often - 2

Disease or Reason - 2

Do you have additional medication to add? (3)

Yes

Medication - 3

Dosage & How Often - 3

Disease or Reason - 3

Medication - 3

Do you have additional medication to add? (4)

Yes

Medication - 4

Dosage & How Often - 4

Disease or Reason - 4

Do you have additional medication to add? (5)

Yes

Medication - 5

Dosage & How Often - 5

Disease or Reason - 5

Do you have additional medication to add? (6)

Yes

Medication - 5

Dosage & How Often - 5

Disease or Reason - 5

Do you have additional medication to add? (7)

Yes

Medication - 7

Dosage & How Often - 7

Disease or Reason - 7

Do you have additional medication to add? (8)

Yes

Medication - 8

Dosage & How Often - 8

Disease or Reason - 8

Do you have additional medication to add? (9)

Yes

Medication - 9

Dosage & How Often - 9

Disease or Reason - 9

Do you have additional medication to add? (10)

Yes

Medication - 10

Dosage & How Often - 10

Disease or Reason - 10

Allergies or Reactions:

1. Medication/ Food/Environmental

1. Reaction

2. Medication/ Food/Environmental

2. Reaction

3. Medication/ Food/Environmental

3. Reaction

4. Medication/ Food/Environmental

4. Reaction

Social History

Do you live:

Describe Other:

Who do you rely on for support and help?

Current Job Occupation:

Are you currently an active member in the military or a Veteran?(Required)

Branch:

Do you smoke?(Required)

Total number of years smoked:

Date Quit:

Cigarettes per day/ packs per day:

Vapes:

Marijuana:

If you do smoke, are you interested in quitting?

Other nicotine use?

Have you had exposure to second hand smoke?

Any recreational drug use current or past?

Drug of choice:

Route:

Date Quit:

Have you been screened for the following:

Do you drink alcohol?(Required)

How many drinks per week?

Type of Alcohol:

How many caffeinated beverages per day?

Caffinated Drink Type:(Required)

Coffee

Tea

Sodas

Energy Drinks

Do you exercise regularly?

If so, how many times per week?

Type of exercise:

Do you feel safe in your home?

Over the last two weeks have you been bothered by: Little interest or pleasure in doing things?

Feeling down, depressed, or hopeless?

How many hours of sleep do you get per night?

Do you wake feeling well rested?

Consent

Telehealth

We offer virtual telehealth visits for most of our services, if you would like to be seen via telehealth: I consent to engage in telehealth with TMWIHC Medical, Dental and Behavioral Health.

Communication

By providing your mobile phone number and email address to TMWIHC, you are agreeing to be contacted by or on behalf of the Clinic and 3rd party company including emails to your email address and text (SMS) messages to your mobile phone and other wireless devices, and the use of an automatic telephone dialing system, artificial voice and prerecorded messages, for the purpose of providing appointment, telehealth or other services and events offered by the Clinic and its business partners. You may opt-out of receiving text (SMS) messages from the business partners at any time by replying with the word STOP from the mobile device receiving the messages. You do not need to provide this consent for text (SMS) messages to receive any services from the Clinic. However, you acknowledge that opting out of receiving text (SMS) messages may impact your experience with the service(s) that rely on communications via text (SMS) messaging. I can withdraw my consent for receiving text (SMS) messages from the Clinic at any time by speaking or writing to TMWIHC.

OFFICE USE ONLY:

PSR Initials:

PSR Initials Date:

Forwarded to PRC by:

Forwarded by Date:

IVS Initials:

IVS Initials Date:

PRC Initials:

PRC Initials Date:

Responsible Party(Required)

I acknowledge I am the responsible party

Enter your name as the responsible party(Required)

Patient Code of Conduct(Required)

I agree with the Patient Code of Conduct

By checking this box you are agreeing to Tuolumne Me-Wuk Indian Health Center's Patient Code of Conduct. You may click the link below to review the Code of Conduct.

Click to view the Patient Code of Conduct

New Patient Packet 2025

Welcome to the Tuolumne Me-Wuk Indian Health Center!

Checklist for all new patients:

Minors need to additionally bring:

Locations

Primary Care

Behavioral Health\ Counseling

Podiatry

MeWu:Ya “The Family Healing Place’”

Dental Clinic

Optometry

Physical Therapy

Emergency Contact:

Tribal Information (If applicable):

Guarantor Information

Guarantor Information / Parent / Guardian:

Insurance Information:

ID & Insurance Card

Patient Information:

Medication List:

Allergies or Reactions:

Social History

Consent

Telehealth

Communication

OFFICE USE ONLY:

Nearby 24-Hour Emergency Rooms:

Quick Links