HIPPA Patient Privacy Act

Additional Forms 

Forms for New Patients (Spanish)

**In order to better serve you and speed up the process during your visit, please feel free to print and complete any of the following forms applicable to your visit.


**Arriving with all necessary paperwork may allow our staff to process your paperwork quicker during check-in while; this will shorten your overall wait time. However, this can shorten your overall wait time.


**Please note that this does not guarantee that you will be seen immediately upon check-in. 


**For patients that don’t have insurance, this practice serves all patients regardless of ability to pay.


**Discounts for essential primary care, dental and mental health services are offered depending on family size and income — based on a Sliding Fee Discount Program.


**The Sliding Fee form can be found below. Please fill out the form and bring it with you on your upcoming appointment.


If you have questions about any of our forms, please Contact a member of our staff for more information.

**As a reminder, please remember to bring your insurance card (if applicable) and photo ID when you visit our office.** 
Adults, please bring a copy of child's immunization record to their appointment.
Adults, if you have medication that is prescribe to you; please bring it to your appointment.

Forms for New Patients 

UNICARE COMMUNITY HEALTH CENTER

This form allows you to obtain your medical record from our facility for yourself and/or for other agencies.

This form allows Unicare Community Health Center to release your medical records to an outside physician and/or medical practice.

HIPPA Patient Privacy Act

​Patient Resources