Patient Forms
Registration Packet
- For new BHA patients.
- For patients who have not seen their BHA provider within the last 24 months.
Re-Registration Form
- For patients who have registered approximately one year ago.
- Re-registration is done annually
Uninsured Patient Information
- The Sliding-Fee Scale is determined by income and Federal Poverty Guidelines.
- A patient will be informed of their Sliding-Fee Scale status after they have completed the registration process with a Registration Counselor.
- Where a patient falls on the Sliding-Fee Scale will determine their copays.
Patient Privacy Notice
- Explains the disclosure of medical information.
- BHA is committed to protect the confidentiality of medical information about our patients and use that information only to care for them properly. We share this information only in the manner described.
Patient Centered Medical Home
- Describes what a patient-centered medical home is.
- Gives the patient an opportunity to understand their role in their health care and their relationship with their provider.
Medical History Forms – Pediatric
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.