Patient Information Forms

Patient Information Forms

New patients will be asked to complete the following forms at their first appointment. If you would like to save time at your first appointment, feel free to fill them out at home and bring them to your first visit with us.

• New Patient Information Form
• Medical Records Release
• Jericho Road HIPAA Consent Form

Sliding Fee Discount Program

Jericho Road Community Health Center welcomes all patients and insurance plans. Should you need assistance with medical coverage, please inquire with a front office receptionist about our sliding scale fee, which is available upon request. No one will be denied access to services due to inability to pay. There are discounts available based on family size and income.

• Sliding Fee Discount Program Information
• Sliding Fee Discount Program Application

Additional Patient Policies

Please also review the following Jericho Road policies:

• No Show Policy
• Controlled Substance Policy
• Notice of Privacy Practices
• Treatment, Payment, and Healthcare Operations

Patient Resources