Registration

Registration Packet

  • New patients must complete forms prior to appointment.
  • Forms can be downloaded, filled out, and brought into any of our locations.
  • Registration packets are also available at any of our locations to pick up and fill out.
  • Registration appointments can be made by walking in or calling ahead to any of our locations.
DOWNLOAD PACKET
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Items To Bring

  • Photo Identification (i.e.: Driver’s License, other proof of Brevard County residency)
  • Social Security Card – if possible
  • Insurance Card OR
  • Proof of Income for last 2 months (i.e.: Paystubs, Bank Statements, Social Security Income, W-2 Statements)
  • Federal Income Tax Return (Required for application for medication assistance)

Brevard Health Alliance is a Patient Centered Medical Home.

  • We provide comprehensive primary care for children, youth and adults.
  • Each patient has an ongoing relationship with a BHA physician trained to provide first contact, continuous and comprehensive care.
  • BHA physicians lead teams of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
  • BHA physicians are responsible for providing for all of the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals.
  • At our facilities, care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
  • BHA is dedicated to the quality of care and the safety of our patients.

Patient Forms

Uninsured Patient Info

Download

Registration Packet

Download
DESCARGA DE PAQUETES

Re-Registration Forms

Download
DESCARGA DE PAQUETES

Patient Privacy Notice

Download

Patient Centered Medical Homes Handout

Download

CONTACT US

If this is a medical emergency please do not use this form to reach out to us, and instead please call 911.
This form is for general inquires only. It can take up to 72 hours to respond to questions submitted here.

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