We understand that good communication is extremely important.  For that reason, we provide  Language Interpretation Services free of charge so all of our patients can receive care in a language most comfortable to them.  Please click here for more information.

If you are ready to begin your care with Family Healthcare of Hagerstown, our forms can be completed ahead of time.

Please Note: All new dental patients should complete the Financial Assistance Form below regardless of insurance coverage. If you have insurance of any kind and feel like you still need financial assistance, complete the Financial Assistance Form below. Be sure to provide the supporting documents explained on the Financial Assistance Form.

PATIENT FORMS
Family Healthcare of Hagerstown complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. FHH does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.  Family Healthcare of Hagerstown:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
If you need these services, please contact our Patient Access Supervisor at 301-745-3777.
Stephanie Walling, Quality Assurance Manager, has been designated as the Civil Rights Coordinator for FHH. If you believe that FHH has failed to provide these services or has discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Stephanie Walling
Family Healthcare of Hagerstown
201 South Cleveland Avenue
Hagerstown, MD 21740
301-745-3777
[email protected].
You can file a grievance in person or by mail, telephone, or email. If you need help filing a grievance, an FHH is available to help you. Please call 301.745.3777.  You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:
U.S. Department of Health and Human Services or
200 Independence Avenue
SW Room 509F
HHH Building Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)