Patient Forms

Registration Packet

New patients must complete forms prior to appointment. Forms can be downloaded, filled out, and brought to your first appointment at any of our locations. Registration packets are also available at any of our locations to pick up and complete. Registration appointments can be made by walking in or calling ahead to any of our locations.

Items to Bring

• Photo Identification (i.e.: Driver’s License or Government Issued Identification, if possible)
• Social Security Card – if possible
• Insurance Card OR
• Proof of Income for last 2 months (i.e.: Paystubs, Bank Statements, Social Security Income, W-2 Statements)
• Federal Income Tax Return (Required for application for medication assistance)

About Brevard Health Alliance

• Brevard Health Alliance is a Primary Care Medical Home. We provide comprehensive primary care for children, youth, and adults.
• Each patient has an ongoing relationship with a BHA provider trained to provide first contact, continuous, and comprehensive care.
• BHA providers lead teams of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
• BHA providers are responsible for providing for all of the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals.
• At our facilities, care is facilitated by registries, information technology, health information exchange and other means to assure patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
• BHA is dedicated to the quality of care and the safety of our patients.

Patient Forms

Registration Packet

For new BHA patient
For patients who have not seen their BHA provider within the last 24 months.

Re-Registration Form

For patients who have registered approximately one year ago.
Re-registration is done annually

Sliding-Fee Scale Information

The Sliding-Fee Scale is determined by income and Federal Poverty Guidelines.
A patient will be informed of their Sliding-Fee Scale status after they have completed the registration process with a BHA Registration Counselor.
Where a patient falls on the Sliding-Fee Scale will determine their copays.

Patient Privacy Notice

Explains the disclosure of medical information.
BHA is committed to protect the confidentiality of medical information about our patients and use that information only to care for them properly. We share this information only in the manner described.

Patient Centered Medical Home

Describes what a patient-centered medical home is.
Gives the patient an opportunity to understand their role in their health care and their relationship with their provider.

Authorization for Release of Medical Information

Download the medical record information release forms below.

Or