• 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!
  • May we contact you at the phone number provided?*
  • May we leave a message?*
  • Do you live or work in Centre County?*
  • Are you currently enrolled as a Penn State or Lock Haven student?*
  • If yes, have you been denied treatment from University Health Services?
  • Have you been serviced by this clinic before?*
  • Are you in the US on a temporary visitor visa?*
  • Do you have ANY health insurance?*
  • Do you have any of the following insurance/benefits? *Check all that apply**
  • Have you been disenrolled from MA since April 2023?*
  • Are there any veterans in the household?*
  • If yes, has the veteran been denied benefits at the VA Clinic?
  • Please specify if the amount above is:*
  • What services are you in need of at this time?*
  • Well you need help filling out forms? *Due to illness, physical limitation, translation problems, reading or writing difficulty**
  • Should be Empty: