Eligibility Forms

Please click here to review eligibility requirements before proceeding.

Please fill out the following forms and bring them to the main clinic or satellite clinic with required documents.

If you cannot come during interview hours, send your forms and documents by fax to: 910-845-5366 or mail to: 201 W Boiling Spring Rd, Southport, NC  28461.  Call 910-845-5333 to speak to an eligibility volunteer if you have not been called in one week.

New patient forms:

Forms to Complete & Return:
NHC Patient Application
NHC Patient Agreements
Financial Aid Application
Controlled Substance Agreement
HealthNet PHI Agreement

For your information:
NHC clinic schedule and contact information
NHC Patient Handbook
NHC Notice of Privacy Practices