Patient Registration

Patient Registration and Financial Screening

The primary patient populations served by Daily Planet Health Services are people experiencing homelessness or housing instability, people living in or around public housing, and people living with HIV. Those seeking services for the first time will be asked a few questions to determine if they qualify to become a new patient and if so, will be asked to complete a Patient Registration/Financial Screening form. Wondering if you qualify? Give us a call at (804) 783-2505.

Patients who may qualify include those who:

  • Live temporarily with a friend or family member (couch surfing or shared housing)
  • Live in a shelter, or someone pays for you to live in a hotel
  • Live in a temporary program (recovery program, recovery house, or re-entry program)
  • Live on the street or a place not meant to be a permanent home (tent, garage, storage unit, car, van, or trailer)
  • Live in a place with no running water, electricity or heat
  • Live in a place where you pay low or no rent because of a disability
  • Are living with HIV

Registration Process

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.

English Forms:

Spanish Forms:

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

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.

Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.

You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit

More information about payments and discounts can be found here.

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.

If you would like to review our privacy practices, click here for English and here for Spanish.

If you would like to review the patient rights and responsibilities, click here for English and here for Spanish.