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Family Healthcare of Hagerstown

201 S. Cleveland Avenue, Hagerstown, Md 21740 | 301-745-3777
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Forms

When you arrive for your appointment, we will ask you to complete the appropriate forms (see forms below). To make your visit easier, please feel free to download and complete the forms and bring them with you when you come to Family Healthcare of Hagerstown.

Please Note: All mental health patients need to also be Family Practice patients; therefore, there are likely no additional forms to complete for mental health patients. Simply completing New Patient information for Family Practice will likely be enough.

Also of Note: All new dental patients should complete the Financial Assistance Form below regardless of insurance coverage. For all other patients, if you have insurance of any kind but still feel like you need financial assistance, we invite you to complete the Financial Assistance Form below to see if you are eligible for the Sliding Fee Program.  All Financial Assistance Forms must be accompanied by  supporting documents as explained on the Financial Assistance Form.

New Patient Forms – Family Practice

New Patient Forms – Dental Adults/Children

Current Patient  Forms – To Be Completed Annually Or As Needed

What Are Your Health Insurance Options?

Staff are happy to help you apply for the Sliding Fee Program; this program is based on household income and can cover costs related to care at the Center. We can also connect you to area agencies that provide enrollment assistance for insurance through Maryland Health Connection and Medicaid. Need other kinds of assistance like housing, transportation, or clothing? If so, ask to speak with one of our Outreach Workers!