The form below is required if you are applying for our sliding fee scale. You will also need to schedule an intake appointment to go over the form with our intake staff.
Please Call to schedule an appointment or to get additional information.
To schedule an appointment or for more information please call us at (307) 635-3618.
If you are experiencing severe symptoms, please call 9-1-1 NOW.
HealthWorks complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Declaración de no discriminación
HealthWorks cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.