Patient Registration and Financial Screening
When you arrive at Daily Planet Health Services as a first time patient you will be asked to fill out a Patient Registration/Financial Screening form. The cost for services is determined during the financial screening process. A sliding fee scale (available here) is used for those who qualify. If you would prefer to complete this paperwork beforehand you may access the form below to print, fill out, and bring with you to your visit to Daily Planet.
- Patient Registration/Financial Screening Form
- Consent for Treatment, Notice of Privacy Practices Acknowledgement, Financial Responsibility Agreement
- Sliding Fee Discount Program Eligibility Notice & Requirements
- COVID-19 Screening
- Formulario de inscripción
- Consentimiento para Tratamiento, Reconocimiento de Prácticas de Privacidad y Acuerdo de responsabilidad financiera
- Comprobante de Ingresos e Información de Copagos
- Evaluación de COVID-19
Registration is available from 8am-11:30am and 1pm-3pm Monday through Friday.
You may also register over the phone or pre-register online. There is no set time for phone registration. If a staff member is not available to complete a registration at the time of your call, they will take your information and call you back when available.
What to Bring With You to Register
- Photo identification (if available)
- Insurance card
- Proof of income (pay stubs) or statement of no income (example: Notice of Action Food Stamps)
- Your most recent tax return, W-2, or a social services determination letter
- Homeless agency referral, if applicable
Further Preparing for Your Visit
The Agency for Healthcare Research and Quality offers a Question Builder tool to help patients get the most out of their medical appointments. Utilizing this tool will help you plan exactly what questions to ask during your visit! The Question Builder tool is available by clicking here.