Prepare for your Appointment

Patient Registration Form

Formulario de inscripción del paciente en Español

We look forward to welcoming you! Here are the steps to prepare for your appointment:

  1. Review our list of locations and select the one most convenient for you.
  2. Call 919-833-3111 to schedule an appointment. We will do our best to schedule your appointment with the provider of your choice, based on availability.
  3. Please print and complete the Registration Packet, which includes the following:
    • Registration Form, Financial Policy, HIPAA Patient Privacy information—all new patients must print, complete and sign.
    • Sliding Fee Discount Program Application – For uninsured patients only. See instructions below.
    • Authorization to Consent to Health Care for Minor – Please print, complete and sign if patient is a minor.
  4. Please arrive 30 minutes prior to your visit with the completed forms above, a photo ID and your insurance card (if you have one).
  5. If you do not have insurance, please follow the instructions below.

call center agent

Learn more about: 

Private Insurance Plans Accepted

 For In-Network participation please contact your insurance company to verify prior to your appointment. 

sandy and patientDon’t have insurance?

We have a Sliding Fee Discount Program based on family size and household income. To complete the application form, you will need the following:

  1. Picture ID for patient and all adult members of your family claimed as dependents.
  2. Proper ID of all children (school ID, insurance card, social security card, birth certificate) for dependents under the age of 18.
  3. Paycheck stubs showing GROSS financial Income for most recent 30 days for all working, claimed dependents living in the home. (Current tax returns, Schedule C if self-employed.)

No Income?

For applicants with zero income, additional supporting documentation will be needed. This may include verification from your sponsor (or the person covering your expenses). Please note these income guidelines are set by the federal government, not Advance Community Health. Please bring the following:

  1. Proof of pension statement, proof of social security/retirement/disability payments. For letter, call Social Security Administration at 1-800-772-1213.
  2. Proof of unemployment. For unemployment letter, call Employment Securities Commission 1-888-737-0259.
  3. Proof of residence if the address on your ID does not match where you are currently living. (utility bill, rental agreement or mortgage)

In addition to printing the Registration Packet above, please print the following forms depending on your needs:

Employment & Income Attestation Form to be completed by you, but if you do not receive traditional pay stubs, your employer will need to fill out the first page.

Certificación del empleo y Verificación de ingresos


Authorization for Release & Request of Information

Autorización para divulgar/soliciatar información

Revocation Authorization for Release & Request of Information

Revocación de la autorización para divulgar/soliciatar información

Notice of Privacy Practices

Notficación de prácticas de privacidad


Last step! Once you have these documents and forms, here are the steps if you do not have insurance:

  1. Please bring your completed Sliding Fee application to the office you wish make an appointment.
  2. When you have completed the forms, please call your provider’s office or deliver it in person during business hours. Faxed forms cannot be accepted unless the site has spoken with you directly. If you are unable to provide us with the Sliding Fee Discount Program Application in advance, please arrive 30 minutes early for your appointment to allow time to complete it at that time.
  3. When your application is approved (usually within days) we will call you and schedule your appointment.
    Please print and complete the HIPPA Patient Privacy form, which is part of the registration packet. Be sure to bring this signed form to your appointment.
  4. We suggest that you bring any previous medical records you may have that would assist our staff with your medical care when you come for your appointment. Please discuss this process with our staff before your first appointment.


Payment (or co-payment) is due at the time of services. We accept cash, in-state checks, money orders, Visa, MasterCard and Discover Card. Please visit our How to Pay page for more information.


Doris Batts-Murray, MD


“I feel that everyone regardless of financial standing, should have access to quality medical care delivered with care and respect.”

Doris Batts-Murray, MD