Become A Patient

DOWNLOAD THE ENROLLMENT FORM HERE

DESCARGUE EL FORMULARIO DE INSCRIPCIÓN AQUÍ     

REGISTRATION PACKET                                     PAQUETE DE REGISTRO 

Ahorre tiempo completando su documentación de registro de pacientes antes de llegar.


Por favor, imprima y complete los siguientes documentos para su visita de atención primaria:

 

*El campo de firma solo está disponible en programas PDF. (IE. Adobe Reader)

Save time by completing your patient registration paperwork before you arrive. 

Please print and complete the following documents for your primary care visit:

*The signature field is only available in PDF programs. (IE. Adobe Reader)

Incomplete or improperly filled out forms will not be processed.

Check and initial all relevant boxes for information to be disclosed, dates of service to be disclosed as well as purpose of disclosure.


DISCLOSURE OF SENSITIVE INFORMATION MUST BE CHECKED AND INITIALED FOR RELEASE TO BE VALID. 

   
Release must be signed and can mailed or dropped off at WNC Community Health Services. 

*Electronic Signature is not permitted per WNCCHS policy.