New Patients

Items to bring to your first visit:

• Photo identification
• Health insurance cards(s)
• Proof of income for sliding scale fee schedule discount
• Medical or dental history
• Medical records (especially) if recent hospital admission or emergency room visits
• List of medications currently taking and/or bottles of medicine
• Foster parent or grandparent: Guardian or custody papers showing custody or child required
• Adult guardian: Power of Attorney
• Co-pay (if applicable)

Fees and Insurance Accepted:

FamilyCare HealthCenter accepts most insurance plans, including Medicaid, Medicare, PEIA, CHIP and Tricare. Services are available on a sliding fee scale, based on income.

FamilyCare HealthCenter has made it easier for first time patients by offering health related forms online. Please select the appropriate form(s), print them out and bring them to your appointment already completed. By offering you this option to print the forms at home in advance of your appointment, you will be able to complete them at your own pace.

Please print the forms on white paper only (when you click a link below the form will load as a pdf file):

ALL PATIENTS:

• Patient Information / Permission to Disclose Health Information
• Permission to Treat a Minor
• Authorization for Use and/or Disclosure of Protected Health Information
• Permission to Treat and Bill for Services
• Medical History

  DENTAL SERVICES:

• Dental Registration and History

  PEDIATRICS:

• Newborn Form
• 2 Months Old Form
• 4 Months Old Form
• 6 Months Old Form
• 9 Months Old Form
• 12 Months Old Form
• 15 Months Old Form
• 18 Months Old Form
• 2 Years Old Form
• 3 Years Old Form
• 4 Years Old Form
• 5-6 Years Old Form
• 7-10 Years Old Form
• 11-18 Years Old Form

  WOMEN ONLY:

• Initial Gyn History
• Return Gyn History

  DISCOUNTED HEALTH CARE:

• Partners’ CAP – Application for Discounted Health Services
• Partners’ CAP – Application for Primary Care Benefits
• Partners’ CAP – Authorization to Use and Disclose Health Information
• Partners’ CAP – Enrollment, Authorization and Release
• Sliding Fee Scale Application
• Medical and dental Sliding Fee Scale Application
• Sliding Fee Scale Program Agreement

If you do not have Acrobat Reader click on the image to download.