The following forms can be filled out online by clicking on the name of the form. If you have any questions about what to bring to your appointment or how to fill out any of the forms below, give us a call at (612) 588-9411 and someone will assist you.

Release of Information form

Sliding Fee Discount Application

Flu Shot Form

Suboxone and Benzodiazepines Waiver

Suboxone Program Expectations and Guidelines

AplicaciĆ³n para Descuento de Tarifa Variable

Flu Shot Form (Spanish)

Mission & Services

Neighborhood HealthSource provides a full range of primary medical and behavioral healthcare services at four clinics in Minneapolis and the north metro. We work hard to make sure everyone in our communities can access the care they need.

We are committed to treating all patients, with and without health insurance, and believe that cost should never be a barrier to care.

Payment Options

Providing care that our patients can afford is vital to our mission. We have an income-based sliding fee program for patients with and without insurance.
Online bill pay is now available! Visit our payment portal to view and pay your bill.

Call: 612.588.9411

Enews Sign-up

Copyright © 2018 - 2024 Neighborhood HealthSource

Neighborhood HealthSource is a Federal Tort Claims Act (FTCA) and FSHCAA Deemed Health Center

This health center receives HRSA Health Center Program grant funding under 42 U.S.C. 254b, and has been deemed a Public Health Service employee under 42 U.S.C. 233(g)-(n).

Neighborhood HealthSource

Neighborhood HealthSource