A Patient Service Rep will contact you with an appointment time to complete your registration. 

Please bring the following documents with you at the time of your appointment.

  1. Proof of Identification (picture id driver license or passport):
  2. Proof of Address (latest residential utility bill)
  3. Please bring your Medicaid, Medipass, Medicare, HMO, Commercial or Private Insurance and social security card(s) if you have one.
  4. Proof of income for each working family member (last years tax return, latest 2 pay stubs or notarized letter from employer) .
  5. Community Health Centers of Pinellas provide services on a sliding fee scale based on family income and size.

    * Are required fields
Contact Information
If you are not the patient, what is your relation to the patient?

If you are not the patient, what is your name?

Please provide us with a contact phone number:
( ) -
 
Patient Information
Ethnic Group (Race)
Marital Status
SSN: (must bring in person)
DOB:
Sex:
*First Name:
Middle Initial:
*Last Name:
Maiden / Previous:
Home Phone:
( ) -
Address:
(Suite/Apt #) :
City
Zip:

E-mail:
Emergency Contact Relationship:
Emergency Contact Name:
Emergency Contact Phone:
( ) -
Patient's Employer:
*Is Insurance Through Employer?:
Yes No
 
Visit Information
*What day would like to schedule the appointment:
[48 hour advance notice required from today's date]

Name of the Referring Doctor:

*Center Preference:
*Time Preference:
Name of the Primary Care Physicians (Doctor) :

What type of care do you need ?

Reason for Visit: (500 Character Max)

 

 
Employer Information
I am Employed I am Unemployed
Address:
(Suite/Apt #) :
City:

Zip:
 
Patient Insurance Information
What type of insurance?

Medicaid Medicare Private Self Pay

(Note secondary insurance information in comments box if needed.)
Insurance Company Name:
Group Number On Insurance Card:
ID Number on Insurance Card if Different than Social Security Number:
Address:
(Suite/Apt #) :
City:

Zip:
Additional Comments: (500 Character Max)

 

 
Policy Holder Information
First Name:
Middle Initial:
Last Name:
SSN:(must bring in person)
DOB:
Address:
(Suite/Apt #) :
City:
Zip:
 

 


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