Forms (with Word Docs)

New Patient

If you’re a new patient at East Texas Community Health Services, feel free to download our New Patient Information Packet below and fill it out at your convenience and bring it in with you your first visit.

New patients will also need to complete our Application for Health Care Assistance and bring it in along with proof of your annual household income to your first visit. This means proof of the income of all wage-earners who live with you. This might include a copy of your and/or your family member’s most recent 1040 tax return form, copies of 2 recent pay check stubs, or a recent letter from an agency that gives you financial support, such as DSHS, SSI, or Unemployment.

Eligibility

For those with limited incomes, services at East Texas Community Health Services, Inc. are billed on a sliding-fee scale based on annual household income and family size. To sign up for the discount, please complete the Application for Health Care Assistance and bring it in along with proof of your annual household income to your first visit. This means proof of the income of all wage-earners who live with you. This might include a copy of your and/or your family member’s most recent 1040 tax return form, copies of 2 recent pay check stubs, or a recent letter from an agency that gives you financial support, such as DSHS, SSI, or Unemployment. The percentage of the full charges you pay is based on your annual household income and family size.

Please note that exact charges are based on specific services and cannot be quoted exactly before your visit. Also, you will be asked to pay at least the co-pay ($25 for medical, $30 for dental) at the time of your visit. Additional charges, if you owe them, will be billed to you.

HIPAA Notice of Privacy Practices

East Texas Community Health Services, Inc. uses your personal information only in ways that you have authorized us to use it as outlined in our Notice of Privacy and Practices (Spanish which you may download below); we don’t sell, rent, or give your personal information to any third party for any other purpose.