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.
Click on the link below to complete the ‘release of information’ form and we will begin that process for you.
Release of InformationAll 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.
Todos los pacientes nuevos deben completar el formulario de consentimiento general antes de ser atendidos en cualquiera de nuestros centros de salud. Puede hacer clic en el botón a la izquierda, a continuación, para completar esto en línea y enviárnoslo. O descargue el formulario en pdf a través del botón de abajo a la derecha, complételo y tráigalo a su primera cita.
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Abarwayi bose bashya bagomba kuzuza urupapuro rwabemereye mbere yo kuboneka mubigo nderabuzima byacu. Urashobora gukanda buto ibumoso, hepfo, kugirango wuzuze ibi kumurongo hanyuma ubitugezeho. Cyangwa ukuremo ifishi ya pdf ukoresheje buto hepfo iburyo, uyuzuze kandi uzane nawe kubonana bwa mbere.
Все новые пациенты должны заполнить форму общего согласия до того, как их примут в любой из наших медицинских центров. Вы можете нажать кнопку слева внизу, чтобы заполнить форму онлайн и отправить ее нам. Или загрузите форму в формате pdf с помощью кнопки ниже справа, заполните ее и возьмите с собой на первую встречу.
Tüm yeni hastalar, sağlık merkezlerimizden herhangi birine görünmeden önce genel onam formunu doldurmalıdır. Aşağıdaki soldaki butona tıklayarak online olarak doldurabilir ve bize iletebilirsiniz. Veya aşağıdaki sağdaki butondan pdf formu indirip doldurun ve ilk randevunuza yanınızda getirin.
Wagonjwa wote wapya lazima wajaze fomu ya idhini ya jumla kabla ya kuonekana katika kituo chetu chochote cha afya. Unaweza kubofya kitufe kilicho upande wa kushoto, chini, ili kujaza hii mtandaoni na kuiwasilisha kwetu. Au pakua fomu ya pdf kupitia kitufe kilicho hapa chini upande wa kulia, ijaze na uje nayo kwenye miadi yako ya kwanza.
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.
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Lorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
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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.
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Lorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
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All new dental patients must complete the form prior to being seen at any of our dental 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.
DownloadLorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
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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.
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Lorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
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Fomu hii ya Ruhusa ya Kushiriki Taarifa za Kimatibabu mara nyingi pia huitwa fomu ya HIPAA. Inaturuhusu kushiriki taarifa zako za kimatibabu na wengine unaowataja. Tumia vitufe vilivyo hapo chini kukamilisha fomu hii, kabla ya miadi yako ya kwanza nasi.
At Five Rivers Health Centers, 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. Please reach out to a Patient Access Representative to apply.
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DescargarLorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
تحميلLorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
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СкачатьKatika Vituo vya Afya vya Five Rivers, tunawapokea wagonjwa bila kujali uwezo wao wa kulipa. Punguzo hutolewa kwa wanachama wa kaya zenye mapato ya jumla ya 200% au chini ya Kiwango cha Umaskini cha Shirikisho. Ili kubaini kama unastahiki, jaza fomu (mtandaoni au chapisha) kabla ya miadi yako ya kwanza. Tafadhali wasiliana na Mwakilishi wa Huduma kwa Wagonjwa ili kuomba.
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DescargarLorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
تحميلLorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
KuramoLorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
СкачатьLorem ipsum dolor sit amet, consectetur adipiscing elit. Suspendisse varius enim in eros elementum tristique. Duis cursus, mi quis viverra ornare, eros dolor interdum nulla, ut commodo diam libero vitae erat. Aenean faucibus nibh et justo cursus id rutrum lorem imperdiet. Nunc ut sem vitae risus tristique posuere.
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 at or below 200% of the Federal Poverty Level. Click here for more detailed information about insurance and payment arrangements.
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