SBHC Appointments - Kennedy Community Health

508-852-1805

Kennedy Community Health School-Based Health Center Appointment Request Form

Student Information

Name

First Last

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Parent/Guardian Information

Parent/Guardian Name

First Last

Parent/Guardian Phone

Insurance Information

Provider/Plan

Policy/Member ID

Appointment Information

Appointment Type (select one)(Required)

School-based Health Center Location (select one)(Required)

Additional notes (optional)

PHONE: 508-852-1805

FAX: 508-853-8593

MEDICAL RECORDS FAX:
508-595-1161

Administrative Offices:

115 NE Cutoff, Bldg. 2, Suite 200, Worcester, MA 01606

LOCATIONS & HOURS
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An FTCA Deemed and NCQA Recognized Facility. We serve all patients regardless of ability to pay. Sliding Fee Scale discounts for essential services are offered if you are eligible, depending upon family size and income. You may apply for a sliding fee discount at the front desk where you receive care. This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.