How to Become a Patient

If you are looking to become a patient of Your Community Health Center, please pick the site that would be the most convenient to you and your family. You can find a list of all locations and phone numbers under our Locations Tab. Once you choose a location, please call the number listed—one of our Reception team members will be happy to assist you in becoming a patient. If you are underinsured or uninsured, our Patient Financial Counselors can help you obtain services you need. You may be eligible for a Sliding Fee Discount, ask one of our Reception team members to apply.

Print and Complete Forms:

Registration Form          Regisitration Form – Spanish

Release of Patient Information

Release of Patient Information – Spanish

Agricultural Status

Dental History

Dental Consent

What should I bring with me on the day of my appointment?
Please remember to bring all your medications and/or prescriptions to your appointment. Also, notify medical/dental personnel of any changes in your medications since your last appointment.

Registration Form
If you are a new patient or have not been seen within the last year, you must complete a registration form.

Insurance Card
Please remember to bring your insurance card(s) with you to your appointment. If you do not have insurance you may apply for the sliding fee discount.

Income Verification/Sliding Fee Discount
All patients registering for services with BJHCHS, Inc. who desire a sliding fee discount are required to provide proof of household income. Verification of income is necessary once a year and anytime there is a change in your household’s income level or size. Documentation that is incomplete or misrepresents the household’s potential earnings will not be accepted as proof of income. Patients that do not desire a discount are not required to present proof of income. Failure to provide proof of income disqualifies the patient from receiving discounted services.
Acceptable Forms of Income Verification:
*Two consecutive recent check stubs from each job
*W-2 form and last tax return
*Statement from Social Security Office
*Unemployment Benefits Statement
*Notarized Statement from Employer
*Statement of Disability