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Affordable healthcare near you, made easy.

New Patient

If you are a new HealthReach patient, please fill out and sign two forms: the Authorization to Disclose Healthcare Information form and the General Consent to Treat form.

Authorization to Disclose Healthcare Information

The Authorization to Disclose Healthcare Information allows us to get your medical records from your previous primary care provider.

Authorization to Disclose Healthcare Information

 

en Español en Français

General Consent to Treat

The General Consent to Treat form allows us to treat you or a patient for whom you are the legal guardian.

General Consent to Treat

 

en Español en Français باللغة العربية

Permission to Share Protected Health Information

The Permission to Share Protected Health Information (P.H.I.) form allows us to verbally share information of your choosing with a friend, family member, or person assisting in your care or payment for your care.

Permission to Share P.H.I.

 

en Español en Français

Affordable Care Program

If you would like to apply for financial assistance for healthcare and/or dental services, click below.

Affordable Care Application

 

en Español en Français

General Information

Finally, you may read HealthReach’s Patient Bill of Rights and Responsibilities and the HealthReach Notice of Privacy Practices. You do not need to return these forms.

Patient Bill of Rights and Responsibilities

Declaración de Derechos y Responsabilidades del Paciente

 

English en Español

 

HealthReach Notice of Privacy Practices

HealthReach Aviso de Prácticas de Privacidad
Avis de HealthReach Concernant les Pratiques en Matière de Confidentialité

 

English en Español en Français

 

Your local healthcare center may request you complete additional forms. These will be provided to you either before or at your appointment.