Mobile Medical Clinic Appointment Request

Language

English (US)
Spanish (Latin America)

Para el español, haga clic en el botón de idioma en el lado derecho y seleccione español.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
What is the best way to contact you?
Email
example@example.com
Are you a patient at One Community Health?
Where do you want to have your appointment?
Why do you need an appointment?

Other
Are you getting care in Washington and 17 years old or younger?

Registration Information
What is your preferred language?

Other
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this also the address where you live?
Physical / Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have health insurance?
What type of insurance do you have?
Front of Insurance Card
Back of Insurance Card
Medicaid Member ID
Name of Insurer
Group ID # (if applicable)
Member ID #
Subscriber Information

NameDate of BirthRelationship to Patient
Claims Address (Usually on the back of your insurance card):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When did your insurance start?

MonthDayYear
Date
Are you the insurance subscriber?
What is the insurance subscriber's name?
Subscriber's date of birth
What is the subscriber's relationship to you?
Who is the responsible party / guarantor (person who's name will be on your billing account)?

We are a community health center and are required to collect income, ethnicity, and race information from all patients. This information helps us receive grant funding to provide you with more services. All answers are confidential and are not shared with any other organization or program.
How many people live in your household?
Estimated yearly household income (check the most accurate)

Other
Are any of the following true for you?
Are you Hispanic or Latino?
Which one or more of the following would you say is your race?

Click submit to finish your form.
Should be Empty: