• Patient Information

    Please provide the requested information about the individual that is registering to become a patient.
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  • Relationship to Patient and Authorization

    Determine who will have access to information concerning medical care, as well as who can bring the patient in for treatment. A Legal Guardian is person who has been court-appointed to care for another person and make decisions on their behalf. A Legal Custodian is a person, other than a parent or guardian, to whom legal custody of the child has been transferred by a court, but does not include a person who has only physical custody of the child.
  • Designation of Health Care Surrogate for a Minor

    All children under the age of 18 need to have the Authorization to Treat A Minor form completed. This form provides Community Health Centers with a list of individuals able to bring the child in for medical or dental treatment.
  • (1) Additional Consent

    Please list all additional individuals you would like to give consent to bring the child in for medical or dental treatment.
  • Notification of Surrogate

    I/We will notify and send a copy of this document to the following person(s) other than my/our surrogate, so that they may know the identity of my/our surrogate.
  • Patient Information Release Consent

    There are times when Community Health Centers (CHC), Inc. will need to contact you or when you may wish to allow family members and friends to have access to information concerning your medical care. Other than as allowed by federal law, we will not release any information to any person except as authorized below by you. Consent is valid unless revoked by the patient or legal guardian at any time.
  • Insurance and Payment Information

    You may qualify for discounted services even if you have health insurance. Discounts are applied to insurance co-pays and deductibles. Qualification is based on the Federal Income levels.
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  • Sliding Discount Program

    You may qualify for discounted services even if you have health insurance. Discounts are applied to insurance co-pays and deductibles. Qualification is based on the Federal Income levels. More information about the Sliding Discount Program can be found in our Resources page.
  • After submission of your Patient Intake Form, you will be redirected to our Sliding Discount Program Application Form. You will need to complete this form before you're able to be considered for the program.
  • Electronic Signature

    I certify that the above facts are true and correct to the best of my knowledge. I am also aware that this information may be randomly audited at any time for verification purposes. Knowingly providing false information may result in termination of services.
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  • All notices and agreements can be download from our Patient Resources page.
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