Patient Information

Patient Forms

Patient Information Disclosure
(from Others)

Patient Paperwork – Adult
(Renewal)

Patient Paperwork – Pediatric
(Renewal)

Sliding Fee Scale Discount Program

Click here to view (or download) the 2024 sliding fee schedule.
Note: a PDF reader is required to view this information

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.  

No-Show and Cancellation Policy

Good Samaritan Health & Wellness Center has updated our No-Show and Cancellation policy in order to better serve our patients.

Your appointment time is reserved specifically for you.  While we understand that emergencies and other unexpected situations do arise, Good Samaritan requests that you provide at least 24-hours’ notice if you are unable to keep an appointment and need to reschedule.

After the first no-show or same day cancellation, patients will be required to pay a non-refundable deposit to book future appointments for a period of six months; $25 for medical appointments and $40 for dental appointments.

The appointment deposit will be charged to the patient, not their insurance company.

If the appointment is kept the deposit will be applied to the appointment fee.  If the appointment is canceled or re-scheduled at least 24 hours prior to the appointment time, the deposit will be applied to the next visit. If you do not cancel or re-schedule the appointment at least 24 hours prior to the appointment time, the deposit will be forfeited and a new deposit will have to be paid in order to book another appointment. A patient will also have the option to come in and wait for a possible appointment opening.

This policy ensures that Good Samaritan Health & Wellness Center can remain consistent with its purpose and promise to provide high-quality, patient-centered care to each of our patients and allows us the opportunity to provide care to another patient.

Thank you for helping us with our mission.