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New Patient Forms & Registration

Registration Information

 

We are required by state and federal regulations to obtain certain information for our records, as well as signed verification that we have provided you with basic information regarding your care at Florida Community Health Centers, Inc.

 

What to Bring:

 

  • Proof of address;
  • Insurance, Medicaid or Medicare Card;
  • If you wish to apply for our “Sliding Fee Scale" please bring your most current tax return. If you do not file taxes, please bring your 3 most recent pay stubs;
  • Records from other doctors and/or hospitals;
  • Listing of all medications you take;
  • Lab, X-ray and special procedure reports you may have had completed;
  • A list of any health concerns you may have.

 

Billing:

 

Patients’ financial responsibilities are based on their financial classification, services received and insurance co-payments. Statements are mailed monthly for unpaid account balances.

 

New Patient Forms:

 

To expediate your visit to our Center, please download, complete, and bring in the following 3 forms (in English or Spanish:

 

Patient Forms in English

Formas de Pacientes en Español

 

New Patient Registration Form «Click Here

 

Registracion Para Pacientes Nuevos «Click Here

 

Health Care Proxy and Contact Permission «Click Here

Carta Poder Del Cuidado Médico y Permiso de Comunicación «Click Here

 

Treatment/Payment Authorization «Click Here

 

Tratamiento/Autorizacion de Pago «Click Here

 

*For additional information, please contact our patient accounting department at the Center where services were received.

Privacy Policy

 

Notice of Privacy «Click Here

Health Information Practices

 

Notificación de Privacidad «Click Here

Y Practicas de Información Medica