Pre-Registration Form

BHCC’s Pre Registration Request

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. BHCC provides services on a sliding fee scale based on schedule D (100%), C (67%) B (33%) A ($25) standard fee according to family income and size for residents residing within BHCC’s service area.