Patient Information

Patient Forms

Patient Information Disclosure
(from Others)

Patient Paperwork – Adult
(Renewal)

Patient Paperwork – Pediatric
(Renewal)

Sliding Fee Scale Discount Program

Payments Accepted

Good Samaritan is a Federally Qualified Health Center and we offer a Sliding Fee Discount Program for those that have no insurance or are under-insured. The Sliding Fee is based on a patient’s family size and documented gross household income.

We also accept Medicare, Medicaid, Veterans Choice and most private insurance plans including: 

• MultiPlan
• United Healthcare
• Wellcare

Cash, credit, and debit cards are accepted. Payment is required at the time of service.