Patient Information
& Forms

Before you arrive, you can fill out our patient forms digitally or print them and bring them with you.

New Patient Registration Information

New patients to Five Rivers Health Centers will be asked to complete required paperwork when they visit us for the first time.  You can print out this paperwork and bring it in, completed, at your first appointment.

Authorized Representative Form

Download

General Consent Form

All new patients must complete the general consent form prior to being seen at any of our health centers. You may click the button on the left, below, to fill this out online and submit it to us. Or download the pdf form via the button below on the right , complete it and bring it with you to your first appointment.

Consentimiento general y acuerdo

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الموافقة العامة والاتفاق

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Ubwumvikane rusange & Amasezerano

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Общее согласие и согласие

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Genel Onay ve Sözleşme

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Makubaliano ya Jumla na Mkataba

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Patient Code of Conduct

The Patient Code of Conduct form must be completed by every new Five Rivers Health Centers patient. Use the buttons below to either complete and submit this form online, prior to your first appointment or download the pdf version of the form and bring it with you, completed, to your first appointment.

Código de conducta del paciente

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مدونة قواعد سلوك المريض

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Amategeko agenga imyitwarire y'abarwayi

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Кодекс поведения пациента

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Hasta Davranış Kuralları

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Maadili ya Mgonjwa

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Permission To Share Medical Information

This Permission to Share Medical Information form is often also called the HIPAA form. It allows us to share your medical information with others that you designate. Use the buttons below to complete this form, prior to your first appointment with us.

Permiso para compartir información médica

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إذن لمشاركة المعلومات الطبية

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Uruhushya rwo Gusangira Amakuru Yubuvuzi

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Разрешение на передачу медицинской информации

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Tıbbi Bilgileri Paylaşma İzni

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Ruhusa ya kushiriki Habari za matibabu

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Sliding Fee Scale Application Form

Individuals without insurance are welcome to become patients at Five Rivers Health Centers, as we accept patients regardless of their ability to pay. Discounts are offered to members of households with combined income of 200% and below of the Federal Poverty Level. To determine if you qualify, complete the form (either online or print) prior to your first appointment. Our Outreach & Enrollment Specialists will be happy to assist you with this process.

Formulario de solicitud de escala de tarifa variable

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نموذج طلب مقياس الرسوم المنزلقة

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Ifishi yo Kwishyuza Ifishi yo gusaba

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Форма заявки на скользящую шкалу

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Kayar Ücret Ölçeği Başvuru Formu

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Insurance and Payment Information

As a Federally-Qualified Health Center, we are able to see all patients, regardless of your ability to pay.  We accept most insurance and provide a sliding fee scale to those who are uninsured.  Click here for more detailed information about insurance and payment arrangements.

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How to use our Telehealth Appointment program

If you have a telehealth appointment scheduled with our providers, you can learn more about how to check-in and use the video program.

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Patient Satisfaction Survey

Your opinion is important to us.  We encourage all of our patients to complete the satisfaction surveys here to share your comments and suggestions on how we can improve.

Take a Survey Now!