Non Emergency Contact Form

Non Emergency Contact Form

If you are having a medical emergency, please call 911 or go to the nearest emergency room.If you are interested in learning about becoming a patient, please call us at 814-231-4043 or submit your information below. Please fill out the following questions to the best of your ability. After completion, a volunteer from CVIM will call you, review your answers, and schedule you for an eligibility meeting, if appropriate. After you complete your eligibility meeting and are established as a patient, you will be scheduled with a medical or dental provider. Thank you!
Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Phone Number*
May we contact you at the phone number provided?*

YesNo
May we leave a message?*

YesNo
Email (Please put n/a if you do not have an email)*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you live or work in Centre County?*

YesNo
Are you currently enrolled as a Penn State or Lock Haven student?*

YesNo
If yes, have you been denied treatment from University Health Services?

YesNo
Have you been serviced by this clinic before?*

YesNo
Are you in the US on a temporary visitor visa?*

YesNo
Do you have ANY health insurance?*

MedicalDentalNone
Do you have any of the following insurance/benefits? *Check all that apply**

Medicare Part A (May qualify for Dental and Case Management Services only)Medicare Part B (May qualify for Dental and Case Management Services only)Medicaid/Medical Assistance/Access (Case Management Services only)Veterans BenefitsCHIPNoneOther
Have you been disenrolled from MA since April 2023?*

YesNo
Are there any veterans in the household?*

YesNo
If yes, has the veteran been denied benefits at the VA Clinic?

YesNo
How many people are in your household and on your tax return? (Spouse, Children)*
What is your household gross income BEFORE taxes?*
Please specify if the amount above is:*

WeeklyMonthlyYearlyNoneOther
What services are you in need of at this time?*

MedicalDentalOther
Well you need help filling out forms? *Due to illness, physical limitation, translation problems, reading or writing difficulty**

YesNo
What is your preferred language?*
How many people are applying for service?*
Please verify that you are human*
Should be Empty: