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Hours: Monday - Thursday: 8:00 - 6:30 | Friday: 8:00 - 4:30
146 Williams Drive, Spencer, West Virginia 25276 | (304) 927-1495

Roane County Family Health Care

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Forms & Notices

Notices

Notice of Privacy Practices

Patient Rights

 

Patient Forms

Patient Health Information Form

Pediatric Health Information Form (if patient is a minor)

Patient Satisfaction Survey

FHC Patient Complaints Incident and Accident Form

 

Sliding Fee

Sliding Fee Cover Letter

Sliding Fee Application

 

Insurance Authorization

Authorization Agreement

 

Employment Application

FHC Application

HRSA & WV DHHR Announcement

"This health center is a Health center Program grantee under 42 U.S.C. 245b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n)."


This program is being presented with financial assistance as a grant from the West Virginia Department of Health and Human Resources and is a FTCA deemed facility.

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