New & Current Patients

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New Patient Information

Welcome to Sacopee Valley Health Center. Our mission is to provide high-quality, patient-centered primary and preventative healthcare services, and to promote optimum health for the community.

We ask all new patients to complete the three forms listed below. We need these forms before your scheduled appointment. You may mail or fax them to:

Attention: Medical Records
70 Main Street
Porter, Maine 04068

New Patient Registration Form

Male Patient History Form

Female Patient History Form

Release Form


New Patient Procedures

Please bring your insurance card(s) with you when you come for your appointment. Your co-pay as payment is expected at the time of service. We will bill most private insurances and accept New Hampshire Medicaid, New Hampshire Kids Gold, MaineCare and Medicare.

Federal assistance helps Sacopee Valley Health Center to provide medical and other services that would not otherwise be available or affordable to area residents. We have a sliding fee scale based on federal guidelines which use family income and family size to figure the amount of the discount.
Fee Discount Information

Please be on time for your appointment. If you are not able to keep it, then please contact the office at
207-625-8126 to reschedule.

Thank you for selecting Sacopee Valley Health Center. We look forward to providing you with high quality patient-centered health care.

Click here to view our Notice of Privacy Practices

Current Patient Info

What is the Fee Discount Program?

The Health Center provides discounts on services to patients who are eligible for our Fee Discount Program. The fee discount can help you pay for costs not covered by your insurance.

What are the Income Guidelines?

You may be eligible if your income falls below these guidelines, EVEN IF YOU HAVE INSURANCE!

Family Size Annual Income
1 $24,120
2 $32,480
3 $40,840
4 $49,200
5 $57,560
6 $65,920
7 $74,280
8 $82,640

Revised February 2017

How do I apply?

Complete the application form. The following must be attached:

  • Proof of current family income (paycheck stubs, copies of unemployment checks, Social Security award letters, child support, etc.)
  • If you are zero income, you will need to provide a letter of support from the person that is supporting you or a written statement from you of how you meet your basic needs.
  • If you are self-employed, please complete the self-employment sheet (three months profit/loss).

If there are special issues you would like us to consider when we review your application, please write them on a separate piece of paper.

Return your completed application form with attachments to the Health Center, either in person or by mailing to:
Outreach & Enrollment 
Sacopee Valley Health Center
70 Main Street Porter ME 04068

All information you provide us in your application is kept completely confidential.

Fee Discount Application

Self-Employment Form

What Services are Covered?

Most Health Center services are covered, including medical, counseling, optometry and dental appointments. These are discounted at the same fee depending where you fall on the income guidelines. You will receive a letter explaining the fee amounts for which you qualify.

When can I apply?

You can apply for the Fee Discount Program at any time. Once you qualify, your enrollment generally lasts for one year. Please submit a new application before your expiration date to avoid a gap in fee discount coverage.

Other Benefits of our Sliding Fee Program

  • Enrollment in the SunRx prescription discount program.
  • Discounts on some services provided through MaineHealth hospital free care program.
  • Discounts on NorDx Lab Services provided at the Health Center.

Once you are enrolled, you will receive more specific information about these benefits.

For more information call:
Jesse LaBrecque
Outreach & Enrollment Specialist
 (207) 625-2239

Sacopee Valley Health Center is an Equal Opportunity Provider and Employer Organization.