New Patient Application Form

Patient Checklist

  • Are you a person who has no insurance?
  • Are you between 18 and 65 years of age?
  • Is your income at 300% of Federal Poverty Level?  Eligibility
  • Are you from Columbia or lower Luzerne Counties?
  • Do you need care that would be given at a doctor’s office, and not at an emergency room?

If you can answer yes to all of the checklist questions, please call for an appointment at the clinic.  Remember there are no walk-ins available, and that we do not prescribe any narcotics.

For your first appointment, please bring a photo ID, your most recent IRS tax form, two recent pay stubs, and a complete list of your medications.  If you have been to the Emergency Room or Careworks recently, please bring copies of your paperwork.

To reduce your wait time at your first appointment, you can print and fill out our new patient paperwork to bring with you by clicking below.

Athena New Patient Paperwork

Athena Papeleo para Pacientes Nuevos en Español