If you want to schedule a visit at Moorhead's School-Based Health Center, operated by Family HealthCare, please call 701-271-3344 to schedule an appointment.
Disclaimer: If you do not want to complete this registration form electronically, please complete and sign a physical form instead. To obtain a physical form to register for services through Family HealthCare, contact your school's health office or stop by our School-Based Health Center at the Moorhead Career Academy.
Enter the name of person FINANCIALLY responsible for this patient
Insurance carriers will be billed for services provided. However, you are ultimately responsible for payment for treatment and care. Please fill out the insurance information below if applicable.
Personal information will be kept confidential and will not be shared with any person who is not directly involved in the care as a part of the Health Insurance Portability and Accountability Act (HIPAA).
Primary Insurance Coverage
Secondary Insurance Coverage
As the patient or patient's guardian:
If you indicated that you would like to sign up for our discounted insurance program, a Family HealthCare representative will contact you at your provided phone number on this form to further assist in the application process. Please call us at 701-271-3344 with any questions.
If eligibility is indicated above, a full application and income verification are required to determine approval. Family HealthCare staff would be pleased to assist with the application process.
By initialing, I understand that Family HealthCare has a sliding fee discount program, and I can apply at any time.
Thank you for choosing Family HealthCare. We are committed to providing you with the highest quality of service and care. We ask that you read and sign this form to acknowledge your understanding of our patient policies.
I have initialed the Patient Financial Responsibility & Authorization section of this intake form. By doing so, I acknowledge that I have read all of the aforementioned statements and will abide by the same, and if I do not, this may disqualify me from receiving care from Family HealthCare.By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
For families who are ongoing patients of Family HealthCare, it may be more convenient to have prior authorization for medical/dental care delivered to minors/adults with disabilities if for some reason the parent/guardian is unable to be present. Please review the following authorization for treatment and complete the information if you want to pre-authorize treatment. Authorized person(s) MUST be 18 years of age or older.
AUTHORIZATION
Person(s) authorized to accompany minor/adult to clinic if legal guardian is unavailable:
I understand that I am giving permission to Family HealthCare to treat the above-named minor/adult with a disability in the event that he/she presents to the clinic with one of the authorized individuals listed above, and that permission is granted to forward pertinent medical or other information from this visit to the insurance company if applicable.
I further understand that parent/guardian must be present for any non-emergent medical/dental surgical procedures including but not limited to tooth extractions and Root Canals. Family HealthCare will do our best to notify guardians of such procedures/paperwork before the appointment date.
I UNDERSTAND THAT THIS AUTHORIZATION WILL REMAIN IN EFFECT FOR ONE (1) YEAR OF SIGNATURE DATE.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Agreement and Signature of this form gives consent for all services provided by Family HealthCare. By selecting specific services here, you are requesting which services you would like your child/yourself to receive from Family HealthCare throughout the Moorhead Area Public Schools district.
This will serve as an Annual Registration form for all visits throughout Family HealthCare.
If you have questions about what healthcare services Family HealthCare has available, please reach out to your program/school district's health office or call our mobile unit department at 701-271-6379.
Immunization resources for parents/children:
Vaccine Information Statements (VIS) for Immunizations Requested on Mobile Unit:
Influenza VIS
HIB VIS
MMR VIS
Meningococcal ACWY VIS
Tdap VIS
Dtap VIS
Hepatitis B VIS
PCV 20 VIS
Meningococcal B VIS
Hepatitis A VIS
Varicella - Chicken Pox VIS
IPV - Polio VIS
Td VIS
HPV VIS
COVID-19 VIS
A copy of this completed form is available upon request.
Your information will be encrypted.
Family HealthCare (FHC) is a family-oriented primary care clinic that provides a wide variety of medical services for patients in the Fargo-Moorhead area.
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