Needed Information and Sliding Fee

Patient Forms and Requirements

All Patients:

ECOFHC Privacy Notice

Patient Handbook (Can be viewed online or printed for your records)

The following forms can be printed and filled out in advance for appointments:

Please bring the following information to each appointment

  • Current Medications
  • Current Insurance, Medicare, Medicaid Card
  • Family History (new patient)
  • Any changes to family history
  • Immunization Records

For Sliding Fee Scale Patients

  • Income Verification for the household (last year’s income tax, check stub, letter from employer, unemployment etc.) must be updated each year
  • Any change of income or household size

Sliding Fee Patient Policy

It is the policy of ECOFHC to provide essential services regardless of the patients ability to pay.  Discounts are offered depending on household income and size.  A computerized sliding fee schedule is used to calculate the basic discount and is updated each year using the federal poverty guidelines.  Once approved, the discount will be honored until the anniversary date of enrollment or unless income verification is updated with new verifications.  Each patient must reapply each year to qualify.