New Patient Forms
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.
- Insurance, Medicaid or Medicare Card;
- If you wish to apply for our “Sliding Fee Scale”, please bring your most current tax return OR your 3 most recent pay stubs,
- Records from other doctors and/or hospitals;
- List 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;
For additional information, please contact our patient accounting department at the Center where services were received.
New patient registration form - English
Registracion para pacientes nuevos