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Release of Medical Records
Patient Health Questionnaires
Adult Medical History for patients 18 and older
Depression Screening PHQ-9 for patients 13 and older
Pediatric Medical History for patients 17 and younger
Dental Medical History for all dental patients
Sliding Fee Discount Program
If you are applying for our Sliding Fee Discount Program, you will need to complete the following:
List all family members and dependents living in your household.
A Family is one or more persons living in one dwelling place who are related by blood, marriage, or law.
A Dependent is someone who lives in your household and qualifies as a dependent for federal tax purposes.
Proof of Income (POI)
You will also need proof of income for all working family members for the past 30 days. We accept check stubs, SSI or Disability award letters, Child Support or Alimony orders, or Unemployment compensation. If you do not have any of these, the following alternative options may apply:
If you do not receive check stubs or have recently started a new job, please have your employer complete this form. It must be dated within fourteen (14) days of your scheduled appointment.
This is a signed form indicating your net income for the past month. You will also need to provide all of the following:
- Pages 1 and 2 from Current Year Tax Returns
- Schedule C, E, or F from Current Year Tax Returns
- Bank statement from the past 30 days
This is a signed form indicating that someone is supporting you at this time. To be eligible to use this form you must be:
- Eighteen (18) or older
- Supported by another individual (cannot be a spouse)