White House Clinics asks that each patient complete paperwork for their patient chart. Use the quicklinks below to navigate to each section or scroll down to view the forms used most often.
- New Patient Paperwork
- Requesting a Medical Record
- Sliding Fee Application
- Confidential Financial Statement
- Sliding Fee Self-Declaration of Income
- Sliding Fee Employer Income Declaration
- Assignments Authorizations Form (Adult)
- Assignments Authorizations Form (Pediatric)
- Confidential Communications Form
- Spanish Forms
- Privacy Notice
You are welcome to fill these out and bring them with you on the day of your appointment, or we will provide them to you when you arrive for your first appointment. We do ask patients new to our office to arrive at least 20 minutes before their appointment time so that our front office staff can make sure all of your paperwork is complete and that we have all of your information in your chart.
Patient Health History
The Health History form for both Adults and Children is a detailed form that allows you to accurately document the health history of the patient. This form is important to fill out completely for your provider so that they have a complete picture of your health. There are separate forms for your medical health history and dental health history.
- Adult Health History (Ages 18 and older)
- Pediatric Health History (Ages 17 and younger)
- Dental Health History (All Ages)
Consent for Treatment
White House Clinics requires all patients to complete documentation that verifies their consent to the treatment provided. We ask that each patient update this form for his or her chart each year. The Consent for Treatment Form (Adult | Pediatric) does the following:
- Gives White House Clinic providers permission to treat you
- States that you agree to pay for services and allows White House Clinics to bill and collect payment from your insurance provider
- Acknowledges that you have received a copy of our Privacy Notice
Patients who are 17 years and younger or adults with a guardian must also have minor consent form on file with us. The Minor Consent Form tells our staff who the legal guardian is as well as who can bring the child to appointments. If you anticipate ever needing a relative or neighbor to bring your child to an appointment you can use this form to indicate who you authorize to do this. This form also allows you to tell us what school or daycare your child attends so that we can send paperwork like school excuses and shot records directly to the school or daycare, saving you a trip to our office.
The Patient Communication Form lets our office know how you would like for us to contact you in regard to your health information (like appointment reminders, test results, and referral information). It also tells our staff if they can leave you a message or if there is anyone like a spouse, child, or friend that our staff can discuss your appointments, billing concerns, or other health information with when you are not available.
To request a copy of your medical records for yourself or to send to another healthcare provider you will need to authorize this office to release those records. For a copy of records for your own needs fill out the Request for Copy of Medical Records. For records to send to another provider or office fill out the Release of Medical Records.
As a Federally Qualified Community Health Center, White House Clinics receive federal funding to provide a discount to uninsured or indigent patients. The federal government provides specific instruction as to the use of this money so White House Clinics follow very standardized procedures for enrollment. Patients interested in enrolling in the discount program meet with the financial counselors at one of our locations, complete the Sliding Fee Application Form, and provide information regarding your household (number of people, income, etc.).