• Patient Annual Registration Form

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  • Parent/Guardian Information

  • Complete if patient is under 18 years old, otherwise, please click Next Page at the bottom to continue

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  • Emergency Contact Information

    (In an emergent situation, the person listed below may be made aware that you are receiving care at our facility)
  • Insurance Information and Patient Preference

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  • Financial Determination

  • Click here to download and print the sliding fee discount application

  • Since Goodwin Community Health receives both state and federal funds, you and your family may be eligible for a discount on the fees charged for services and supplies you receive.  This discount is based on family size and household income.  If you wish to apply for a discount, you will need to answer the questions below and supply proof of income 30 days from the date this application is signed.  If you are applying for our sliding fee, once proof of income is received, you will be eligible for that discount for one year.

    The following are appropriate examples of types of income:

    • Social Security
    • Retirement
    • Business
    • Welfare Payments
    • Child Support
    • Alimony
    • Disability
    • Others

    The following are appropriate examples of proof of income:

    • 4 weeks of current and consecutive pay stubs
    • Current tax return
    • 4 weeks of Unemployment check stubs
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  • The above information supplied is current and accurate to the best of my knowledge.  Should inaccurate information be provided, any discount given will be reversed based on this information.

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