Health Forms

Health Forms

  1. Health Forms
  2. Policy and Information
Form NameFile
Caregiver Authorization Affidavit PDF
Informed Consent to Receive Family Planning Services & Contraceptive Supplies PDF
Patient Registration Packet PDF
Authorization for Release of Information PDF
Patient Information Sheet see Policy tab
Sliding Fee Discount Eligibility Determination Form see Policy tab
Notice of Privacy Practices see Policy tab
Prescription Policy

All prescription refills must be approved by your provider. PLEASE PLAN AHEAD.

Prescription refills will only be approved if your provider feels it is safe for you to receive a refill without coming in for an office visit.

Appointment Policy

Our health center network is here to serve our community and meet the need for primary health care services. Our patients are typically seen by appointment. Walk-ins may be seen based on available clinic resources.

If you need to cancel an appointment, we would appreciate at least a 24 hour notice so that we can give that time to another patient.We request that you arrive to your scheduled appointment as follows:

A. New Dental or Medical Patient (not seen within the last 2 years): 40 minutes prior to your appointment.

B. Established Dental or Medical Patient (seen at Bay Clinic within the last 2 years): 20 minutes prior to your appointment.

C. First Obstetrics Appointment: 1 hour prior to your appointment.

Failure to arrive as outlined above may result in your appointment being rescheduled.


Patient Information Sheet

Please request a Patient Information Sheet in person from a Patient Services Representative at any of our health center locations. Mahalo!

Sliding Fee Discount Eligibility Determination Form

If your income is at or below the federal poverty guidelines, you may qualify for a discount on the cost of your medical care. In order to determine whether you qualify, you must provide us with documentation of your income. This can include:

A. Most recent paycheck stub;

B. Most recent welfare benefit statement;

C. Most recent food stamp benefit statement;

D. Most recent unemployment or workers compensation benefit statement;

E. Most recent tax return;

F. Any other document that will prove how much income you receive.

If you do not receive any income, you must sign a statement explaining how you are being supported.

If you do not provide proof of your income at the time of your visit, you will be charged for the full cost of your medical care. Your proof of income statement will be valid for 1 year. After that time, new proof of your income will be required.

Depending on your income, you may be eligible to receive up to a 75% discount on the cost of your medical care or be charged with a nominal fee. Income guidelines are set by the federal government, not The Bay Clinic, Inc. If you are referred to another medical provider or facility for additional lab tests, x-rays or treatment, you will receive a separate bill from that facility, and will be responsible for the full cost of those services. Your Bay Clinic, Inc. medical provider may refer you to additional services because he or she may feel that it is an important part of your medical care. The Bay Clinic, Inc. will not pay for or provide discounts for any referred services. Occasionally, The Bay Clinic, Inc. receives grants to help pay for referred services such as breast and cervical cancer screenings, or chest x-rays. Please ask your nurse if you qualify for this support.

If you have any questions about sliding fee discounts, please speak to a Patient Services Representative at any one of our health center locations.. If they are unable to answer your question(s), you will be referred to someone who can.


Providing affordable, high-quality, and comprehensive health care services to East Hawai'i residents for over 35 years.

Call Center: (808) 333-3600