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Caring For Our Community

Forms & Sliding Scale Fee Application

Save time by completing these patient information packs before your visit with GFHS!

GFHS is dedicated to providing quality health care, health education and preventive care services to all members of the community regardless of financial barriers (ability to pay) through the regular publication of a sliding fee scale.  Discounts described on the sliding scale reflect the eligible patient’s obligation based on family household income in relation to the Federal Poverty Guidelines, published annually.  GFHS annually revises and re-issues its sliding scale to reflect changes in the Federal Poverty Guidelines.  Our sliding scale fee application forms are provided below.

For your Medical and/or Behavioral Health Visit

SPANISH

Adult Patient Information Pack (Spanish)

Pediatric Patient Information Pack (Spanish)

Sliding Scale Fee Application (Spanish)

Consent to Release Patient Information (Spanish)

ENGLISH

Adult Patient Information Pack (English) 

Pediatric Patient Information Pack (English)

Sliding Scale Fee Application (English)

Consent to Release Patient Information (English)

Revocation of Consent to Release Patient Information

For your Dental Visit:

SPANISH

Adult Patient Information Pack (Spanish)

Pediatric Patient Information Pack (Spanish)

Sliding Scale Fee Application (Spanish)

ENGLISH

Adult Patient Information Pack (English)

Pediatric Patient Information Pack (English)

Sliding Scale Fee Application (English)