Applications & Forms

Medical Registration:


New medical patients to HAHC need to complete the following forms for their first visit. Completing these in advance will help shorten your registration time. In addition to the forms, bring your current insurance cards, photo id, and all medications. If you will be applying for sliding fee also bring the sliding fee application and required proof of income. The sliding fee application is below.

Medical Registration Application
Medical New Patient Packet.docx
Microsoft Word document [103.9 KB]
Record Release Form
Record Release Autorization 2014.docx
Microsoft Word document [161.0 KB]
Consent to Disclose Information
PHI release form 2014.docx
Microsoft Word document [77.6 KB]
Intitial Health History
Initial Health History.doc
Microsoft Word document [207.5 KB]

Dental Registration:

New dental patients to HAHC need to complete the following forms for their first visit. Completing these in advance will help shorten your registration time. In addition to the forms, bring your current insurance cards and photo id. If you will be applying for sliding fee also bring the sliding fee application and required proof of income. The sliding fee application and information is below.

Dental Registration Appplication
Dental New Patient Packet.docx
Microsoft Word document [93.2 KB]
Record Release Form
Record Release Autorization 2014.docx
Microsoft Word document [161.0 KB]
Consent to Disclose Information
PHI release form 2014.docx
Microsoft Word document [77.6 KB]
Dental Health History
Dental health history.docx
Microsoft Word document [14.9 KB]

Sliding Fee Application:

Patients applying for the sliding fee will need to complete the following application and supply required proof of income. If you have any questions regarding the sliding fee please call the office.

Sliding Fee Application
Sliding Fee Application.docx
Microsoft Word document [81.0 KB]

Additional Forms:

Record Release Form
Record Release Autorization 2014.docx
Microsoft Word document [161.0 KB]
Consent to Disclose Information
PHI release form 2014.docx
Microsoft Word document [77.6 KB]
Patient Satisfaction Survey:
patientsatisfactionsurvey.docx
Microsoft Word document [49.4 KB]

Hyndman Area Health Center

 

Located at:
144 Fifth Avenue
Hyndman, PA 15545

 

Phone: 814-842-3206

Fax:814-842-3746

 

 




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