Forms

New Patient Forms
If you are a new patient, you will need to complete the form below before seeing a health care provider. Print and fill out the New Patient Form in the comfort of your home and avoid having to come 30 minutes earlier for your appointment to do paperwork.

New Adult Patient Form
New Child Patient Form

Eligibility Forms

An eligibility appointment is very important in order to assess whether or not you qualify for various programs and/or financial aid from the government. Our Eligibility Specialists are highly-trained and will match you with the best options you have so that you will benefit from the most affordable health care solution.

Eligibility Requirements for Legacy Montrose Campus

Eligibility Requirements for Legacy Lyons Campus

Eligibility Requirements for Legacy Southwest Campus

Eligibility Requirements for Legacy South Park Campus


Patient Contract

We take our responsibility towards you as a patient very seriously and expect the same in return. Please read the "Patient Contract" to understand our expectations of you and our commitment to you.

Patient Contract

 

This health center is a Health Center Program grantee under the Public Health Service Act, Section 330, 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n). All remedies brought forth to a health center employee may be subject to remedy under the Federal Tort Claims Act (FTCA).