Third Street Family Health Services - Behavioral, Dental, Medical, OB/GYN, Podiatry, Pediatrics, Suboxone, 44906, 44875

We provide behavioral health, suboxone, dental, OB/GYN, women's care, medical, pediatrics, and podiatry. We have nine locations and all can be found in Mansfield or Shelby, Ohio. Our main location is located at 600 West Third Street, Mansfield, OH 44906.

New Patients

Welcome to Third Street Family Health Services. In order to prepare for your first appointment with us, here is some basic information and forms to have ready:

General Information

  • For your first appointment, you should expect to be here for up to 2 hours. However, if you can manage to bring in the completed forms below, that time will be greatly reduced.
  • Your first appointment will establish you as a new patient. Subsequent appointments will be made for care from one of our providers.

Items Needed at First Appointment

  • Social Security Number
  • Shot Records (Children)
  • Identification (Drivers License, State ID Card, Social Security Card)
  • Letters of Court-Appointed Custody or Guardianship, If applicable
  • Medication List or Pill Bottles
  • Insurance Card
  • If no Insurance, Proof of Household Income will be required to apply for Sliding Fee:

Proof of Household Income Includes:

You must bring in ALL items that apply to your house-hold

  • Proof of Alimony
  • Pay Stubs for the Past 30 Days
    • We will NOT accept bank statements.
    • We will NOT accept W2′s as proof of income.
  • Unemployment or Workers Compensation award letter or check stub
  • Social Security, Disability, or Retirement award letter
  • Veteran’s Benefits
  • Pension check stub or award letter
  • Letter from Employer
  • ADC Income
  • Letter from anyone providing you with financial support, this includes housing and food
  • If the patient is self-employed – full tax return with schedule C

New Patient Forms

Download the file below if you would like to fill out your packet and send it in through email.

Fill & Send New Patient Packet Requires Adobe Reader or PDF viewer
Download Reader
(Gmail and Yahoo accounts only)

All other paper work will be filled out when you come in for your appointment.

Printable Forms

New Patients

Welcome to Third Street Family Health Services. In order to prepare for your first appointment with us, here is some basic information and forms to have ready:

General Information

  • For your first appointment, you should expect to be here for up to 2 hours. However, if you can manage to bring in the completed forms below, that time will be greatly reduced.
  • Your first appointment will establish you as a new patient. Subsequent appointments will be made for care from one of our providers.

Items Needed at First Appointment

  • Social Security Number
  • Shot Records (Children)
  • Identification (Drivers License, State ID Card, Social Security Card)
  • Letters of Court-Appointed Custody or Guardianship, If applicable
  • Medication List or Pill Bottles
  • Insurance Card
  • If no Insurance, Proof of Household Income will be required to apply for Sliding Fee:

Proof of Household Income Includes:

You must bring in ALL items that apply to your house-hold

  • Proof of Alimony
  • Pay Stubs for the Past 30 Days
    • We will NOT accept bank statements.
    • We will NOT accept W2′s as proof of income.
  • Unemployment or Workers Compensation award letter or check stub
  • Social Security, Disability, or Retirement award letter
  • Veteran’s Benefits
  • Pension check stub or award letter
  • Letter from Employer
  • ADC Income
  • Letter from anyone providing you with financial support, this includes housing and food
  • If the patient is self-employed – full tax return with schedule C

New Patient Forms

Download the file below if you would like to fill out your packet and send it in through email. Note: Packet cannot be completed on smart phones.

Fill & Send New Patient Packet
 
Requires Adobe Reader or PDF viewer
Download Reader
(Gmail and Yahoo accounts only)

All other paper work will be filled out when you come in for your appointment.

Printable Forms

New Patient Packet
 
Welcome Letter
 
Patient Medical History
 
Patient Info
 
Sliding Fee Application
 
Accommodation
 
Consent for Treatment
 
NPP Acknowledge
 
Minor Demographics

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Third Street Family Health Services is a FTCA Deemed facility

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