Health Center Registration

Call the Community Health Center or social service that fits your medical or social needs for an appointment. Prior to your first appointment, please plan on registering as a new patient. If time allows the Community Health Center or social service will mail registration forms to you or all the forms you need are located here on our web site. In addition to our “new patient registration forms” Shawnee Health Service will need the following:

• Copy of your insurance, Medicare, or Medicaid card if applicable.
• List of current medications

Health Center New Patient Registration Forms

• Patient Registration Form
• Family Income Screen
• Medical History Form
  • Pediatric
  • Adolescent
  • Adult
  • Shawnee Women’s Health and Family Medicine Form 
• Confidential Communication Form – Optional
• Confidential Services for MINORS: Disclosure – Exceptions to the general rule of parental consent for treatment of minors (under the age of 18) allow minors to receive services without their parents or legal guardian’s knowledge or consent. Confidential services are available if you are
  • a pregnant minor
  • a parenting minor
  • have a medical emergency
  • a married minor
  • a victim of a sexual assault
  • needing outpatient counseling (up to 5 visits) and you are 12 or older
  • needing birth control and a doctor or a family planning health provider recommends it
  • needing HIV testing and you are 12 years or older

School Based Health Center Registration Forms

• Adult Registration Form
  • Adult School Based Registration Form
• Student Registration Forms
  • Marion Wellness Center Form
  • Terrier Care Center Form
• Family Income Screen
• Medical History Form
  • Pediatric
  • Adolescent
  • Adult
• Confidential Communication Form – Optional
• Confidential Services for MINORS: Disclosure – Exceptions to the general rule of parental consent for treatment of minors (under the age of 18) allow minors to receive services without their parents or legal guardian’s knowledge or consent. Confidential services are available if you are
  • a pregnant minor
  • a parenting minor
  • have a medical emergency
  • a married minor
  • a victim of a sexual assault
  • needing outpatient counseling (up to 5 visits) and you are 12 or older
  • needing birth control and a doctor or a family planning health provider recommends it
  • needing HIV testing and you are 12 years or older

Southern Illinois Respiratory Disease Clinic Registration Form

• Patient Registration Form
• Family Income Screen
• Confidential Communication Form – Optional
  

Senior Services Registration

Informational Forms:

• Authorization for Release of Protected Health Information
• Shawnee Health Service Notice of Privacy Practices
• Clients Rights and Responsibilities