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    Northeast Missouri Health Council
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    Patient Forms

    New Patient at any Family Health Site 0-17 yrs
    Slide Income Guidelines
    New Patient at any Family Health Site 18+ yrs
    Sliding Fee Application
    New Patient at any Dental Site 0-17 yrs
    Proof of Unemployment Form for Slide
    New Patient at any Dental Site 18+ yrs
    Medical and Dental Record Release Form (FROM NMHC)
    Mobile Dental Unit Packet
    Medical and Dental Record Release Form (TO NMHC)
    New Patient at NE Pediatrics 0-4 yrs
    Behavioral Health Record Release Form
    New Patient at NE Pediatrics 5-18 yrs
    Patient Satisfaction Survey
    New OB Patient at OBGYN Specialty Group
    NMHC HIPAA Notice of Privacy Practices
    New GYN Patient at OBGYN Specialty Group
    NMHC HIPAA Notice SPANISH
    HIPPA Form 2022
    NMHC HIPAA Notice FRENCH
    Cystic Fibrosis Consent
    VA 1010EZ
    VA 1010EZRenewal
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    Northeast Family Health

    1506 Crown Drive       

    Kirksville, MO  63501

    Phone:  (660) 627-4493

    Hours: M, T, TH: 7:30 a.m. - 12:00 p.m.

    1:00 p.m. - 6 p.m.

    Wed: 7:30 a.m. - 12:00 p.m

    1:00 p.m. - 5 p.m.

    Fri: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

    Northeast Pediatrics 

    402 W. Jefferson Suite A

    Kirksville, MO  63501

    Phone:  (660) 627-2229

    After Hours: 1-833-745-2217

    Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

    OB/GYN Specialty Group 

    402 W. Jefferson Suite B

    Kirksville, MO 63501

    Phone: (660) 665-3555

    Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

    Edina Family Health

    104 E. Jackson

    Edina, MO  63537

    Phone: (660) 397-3517

    Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

    Northeast Dental 

    402 W. Jefferson Suite C

    Kirksville, MO  63501

    Phone:  (660) 665-2741

    Hours: 7:45 a.m.-11:45 p.m. & 12:45 p.m.-4:45

    Macon Family Health & Macon Dental

    209 N. Missouri

    Macon, MO  63552

    Phone:  (660) 395-5045

    Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

    Kahoka Dental 

    22291 US Highway 136

    Kahoka, MO  63445

    Phone: (660) 727-1500

    Hours: M, T, W, F 7:00 a.m. - 12:00 p.m.

    1:00 p.m. - 4:00 p.m.

    Thursday: 7:00 a.m. - 12:00 p.m.

    Northeast Family Health - Milan 

    52334 S. Business Highway 5

    Milan, MO  63556

    Phone: (660) 265-1042

    Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

    Northeast Behavioral Health 

    1410 Crown Drive

    Kirksville, MO 63501

    Phone: (660) 627-3621

    Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

    Diabetes & Nutrition Center

    1506 Crown Drive

    Kirksville, MO  63501

    Phone: (660) 627-4493,  Ext. 412

    Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

    Kirksville Veterans Clinic

    506 Rosewood Drive

    Kirksville, MO 63501

    Phone: (660) 627-8387

    Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

    Business Office

    1416 Crown Drive

    Kirksville, MO  63501

    Phone: (660) 627-5757, Ext. 6

    Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

    Administrative Offices 

    1416 Crown Drive

    Kirksville, MO  63501

    Phone:  (660) 627-5757 

    Hours: 8 a.m.-12 p.m. & 1 p.m.-5 p.m.

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    This health center is a Health Center Program grantee under 42 U.S.C 254b, and deemed Public Health Service employee under 42 U.S. C. 233(g)-(n)
     
    Northeast Missouri Health Council is a FTCA deemed facility. Malpractice coverage is provided under the Federal Tort Claims Act (FTCA) pursuant to 42 U.S.C. 233(g)-(n).
     
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