In order to better serve you and speed up the process during your visit, please feel free to print and complete any of the following forms applicable to your visit.
Arriving with all the necessary paperwork may allow our staff to process your paperwork quicker during check-in. However, this can shorten your overall wait time.
For patients that don’t have insurance, this practice serves all patients regardless of ability to pay.
Discounts for essential primary care, dental and mental health services are offered depending on family size and income — based on a Sliding Fee Discount Program.
The Sliding Fee form can be found below. Please fill out the form and bring it with you on your upcoming appointment.
If you have questions about any of our forms, please contact a member of our staff for more information.
As a reminder, please remember to bring your insurance card (if applicable) and photo ID when you visit our office.
Adults, please bring a copy of your child’s immunization record to their appointment.
Adults, if you have medication that is prescribed to you, please bring it to your appointment.
FORMS FOR NEW PATIENTS
FORMULARIOS PARA PACIENTES NUEVOS
HIPAA PATIENT PRIVACY ACT
LEY DE PRIVACIDAD HIPAA
ADDITIONAL FORMS / FORMULARIOS ADICIONALES
This form allows Unicare Community Health Center to release your medical records to an outside physician and/or medical practice.
This form also allows you to obtain your medical record from our facility for yourself and/or for other agencies.
- Authorization for the Release of Protected Health Information
- Dental and Medical History
- CHDP Application (English)
- CHDP Application (Spanish)
- Family PACT Application (English)
- Family PACT Application (Spanish)
- American Red Cross (Los Angeles County)
- American Red Cross (San Bernardino County)
- Apply for Medi-Cal
- Centers of Disease Control and Prevention
- Child Protective Services (Los Angeles County)
- Child Protective Services (San Bernardino County)
- Domestic Violence Help (Los Angeles County)
- Domestic Violence Help (San Bernardino County)
- Emergency Preparedness and Response Program (Los Angeles County)
- Emergency Preparedness and Response Program (San Bernardino County)
- Food Bank
- Homeless Shelter
- Poison Control
- Suicide Crisis Hotline