New Patient Registration

Reading a Digital Book

Call Samaritan Health Ministries

to schedule an eligibility assessment appointment.

Your First Visit

Thank you for choosing Samaritan Health Ministries as your new medical home.

Making an appointment is easy and convenient. We have one central phone number that enables you to make appointments for all our services.

Before your eligibility assessment appointment you can save time by filling out the patient registration forms listed below.

 

Please bring the following to your first appointment:

  • Current photo ID. (cannot be expired)

  • Proof of address. (utility bill, auto insurance, voter registration, government issued document)

  • Proof of combined household income for the past 30 days. (pay stubs, W2, current tax return, unemployment benefits, SS benefits, child support/alimony)

You will be interviewed, either by phone or in person, by one of our financial screeners to determine income level and family size before you can be seen by a SHM provider.

We want your experience to be as easy and comfortable as possible. If you have any questions, please feel free to call or email us.

Download Documents

For your convenience, here are pre-visit forms to prepare you for your first visit with us.

Email ALL documents to:

jhenriksen@theshm.org

Additional proof of income/address

Proof of income can also include:

  • Paystubs reflecting a 30 to 60 day period. 

  • Employer's written verification of gross monthly income or the Employment Verification Form (Form 128).

  • Income tax return.

  • Printout of child support payments.

  • Statement of support from relative or friend providing financial support. 

  • Unemployment benefits statement or letter from the Texas Workforce Commission.

  • Award letters, court orders, or public decrees to verify support payments. 

  • Notes for cash contributions. 

Proof of address can also include:

  • Current voter registration

  • Rent or utility receipts for one month

  • Car registration

  • School records

  • Property tax receipt