Welcome to Lifespan!  Included below are general forms for new and existing patients.  If you need assistance, contact our patient account specialists at (731) 925-2300.

If you are underinsured or inunsured, our Patient Financial Counselors can assist you to ensure you receive the services you require.  You may also be elgible for our sliding fee discount (see form below).

If you are looking to become a patient of your community health center, please pick the site that would be the most convenient to you and your family.  You can find a list of all locations and phone numbers under our Locations tab.  Once you choose a location, please call the number listed – one of our reception team members will be happy to assist you in becoming a patient. If you are underinsured or uninsured, our patient financial counselors can help you obtain services you need.  You may be eligible for a Sliding Fee Discount, ask one of your reception team members to apply.

Print & Complete Forms Before Arriving.

Minimum Payment Notes

Payment is due at the time of your appointment.  Payment amounts are as follows:

Medicaid without a Copay or VA = $0.00

Medicare without a Secondary = $15.00

Sliding Scale = See Sliding Scale Info

Insurance with a Deductible (Without a Copay) = $60.00

Self pay Contract = $60.00

What should I bring with me on the day of my appointment?

Please remember to bring all your medications and/or prescriptions to your appointment.  Also, notify medical/dental personnel of any changes in your medications since your last appointment.

Registration Form

If you are a new patient or have not been seen within the last year, you must complete a registration form.

Insurance Card

Please remember to bring your insurance card(s) with you to your appointment. If you do not have insurance you may apply for the sliding fee discount.

Knowing your coverage and information BEFORE visiting is vital

To helping alleviate wait times in the office.

Income Verification/Sliding Fee Discount

All patients registering for services with Lifespan Health who desire a sliding fee discount are required to provide proof of household income. Verification of income is necessary once a year and anytime there is a change in your household’s income level or size. Documentation that is incomplete or misrepresents the household’s potential earnings will not be accepted as proof of income. Patients that do not desire a discount are not required to present proof of income. Failure to provide proof of income disqualifies the patient from receiving discounted services.

Acceptable Forms of Income Verification:

*Two consecutive recent check stubs from each job
*W-2 form and last tax return
*Statement from Social Security Office
*Unemployment Benefits Statement
*Notarized Statement from Employer
*Statement of Disability

Release of Medical Records

Lifespan is willing to release all medical records with a signed release and a nominal fee to produce a copy of all records.  We may also provide an electronic version of your medical records upon request.  All medical record release requests are handled by our medical records department in order to keep your information as secure and confidential as possible.