Member Forms

New Member Forms
If you are a new member and want to get a head start on your intake, you can print and fill out these forms in the comfort of your home and avoid having to come earlier for your appointment to do paperwork.

Authorization to Obtain and Release Information

Care Coordination Consent

Emergency Contacts

Behavioral Health Consent Form 

Eligibility Forms
An eligibility appointment is very important in order to assess whether or not you qualify for various programs and/or financial aid from the government. Our staff are highly trained and will match you with the best options you have so that you will benefit from the most affordable health care solution.

Eligibility Requirements

Patient Bill of Rights and Responsibilities
We take our responsibility towards you as a patient very seriously and expect the same in return. Please read the "Patient Bill of Rights and Responsibilities" to understand our expectations of you and our commitment to you.

Patient Bill of Rights and Responsibilities

Protected Health Information

Medical Records Department Fax 855-684-6060