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Patient Care:

Forms

Below are patient forms and notices that can be reviewed and completed in advance of appointments to expedite the time of your visit.

As a reminder, First Choice Health Centers serves patients of all ages and backgrounds regardless of insurance status or ability to pay. We accept most insurance plans and offer a sliding-fee scale for patients who are uninsured or under-insured.

Patients rights and responsibilities-Derechos y responsabilidades de os pacientes

Permission to Share Health Info-Autorización para la divulgación de información sanitaria protegida

Permission to Share Medical Info-Permiso Para Compartir Informacion Medica

Declaration of Identity, Address and Income-Declaracion de Ingresos, Identidad y Ingresos

2023 Sliding Fee/Fed Poverty Guidelines–2023 Tarifa variable/Pautas federales de pobreza

Notice of privacy practices-Aviso de prácticas de privacidad

School Based Dental Enrollment-Programa dental en la escuela registro

School Based Medical Registration-Programa de salud y dental en la escuela registro

School-Based Healthcare Pediatric History

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This health center receives HHS funding and has federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.