Saban Community Clinic

Welcome to Saban Community Clinic

ESPAÑOL

We are happy you have chosen us for your care.
To register, please complete this form. Several items below will help us ensure that we are meeting your needs.

    PATIENT DEMOGRAPHICS





    Hint
    If you don’t have a Social Security Number, type 999-99-999

    Sexual Orientation: (Select all that apply)

    Gender: (Select One)

    How may we contact you? (Select all that apply)

    My–Chart is a secure online portal where you can view and manage your medical information whenever it's most convenient for you. Features include: Schedule appointments online with your doctor and urgent care.

    SCC will send you mail to the below address. Would you like to communicate with us electronically? If yes, please provide email address so that we can establish an account for you.







    *
    Hint
    Please share an active email to receive clinic updates

    Race:(Select all that apply)

    Ethnicity Group:(Select One)

    Are you a U.S Veteran:(Select One)

    EMERGENCY CONTACT
    Contact Name:






    What Clinic Location is your preference? (Select One)

    PATIENT ASSISTANCE

    Low Vision? (Select One)

    Need an interpreter?

    Hard of hearing? (Select One)

    How confident were you filling out this form? (Select One)

    Disability status: (Select One)

    Preferred Language:

    LIVING STATUS INFORMATION
    Gathering of the following information is to better service your housing needs.

    Presently where are you living?

    FINANCIAL INFORMATION
    We collect your family size and income information to determine the appropriate contribution amount for your care. You may need to show proof of income to determine your federal poverty level to identify affordable options to your care
    Hint
    Immediate family only

    Acknowledgment of Responsibility for payments for Services and assignment of Benefits

    • I understand that I am responsible for all charges and fees for my care, except any that might be covered by insurance accepted at SCC.
    • I understand that payments, including co-insurance, co pays and self-pay/ Sliding Fee payments, is due at the time of Registration.
    • The information on this form is true to the best of my knowledge.

    Please use your mouse or touchpad to sign your name in the grey section below, then click “Submit Form” to submit your request.