New Patients
Community Health Centers, Inc. has made it easier for first time patients by offering health related forms online. Please select the appropriate form(s), print them out and bring them to your appointment already completed. By offering you this option to print the forms at home in advance of your appointment, you will be able to complete them at your own pace. Please print the forms on white paper only.
- Adult Health Questionnaire
- Pediatric Health Questionnaire
- Dental Health Questionnaire
- New Patient Registration Form
- Employment Verification Form (English)
- Employment Verification Form (Spanish)
- Sliding Scale Application
- Sliding Scale Brochure (English)
- Sliding Scale Brochure (Spanish)
- Female History Questionnaire
- Patient Authorization to Use or Disclose (English)
- Patient Authorization to Use or Disclose (Spanish)
- Alcohol Misuse Abuse Questionnaire
- Sexual History Questionnaire
- Tobacco Control Questionnaire
Items to bring to your first visit
- Photo identification
- Health insurance card(s)
- Social Security card
- Proof of income for sliding scale fee schedule discount
- Medical or dental history
- Medical records (especially) if recent hospital admission or emergency room visit
- All medications currently taking
- Foster parent or grandparent: Guardian or custody papers showing custody of child required
- Adult guardian: Power of Attorney
Fees and Insurance Accepted
Uninsured patients are offered discounted services through an income verification process. CHC accepts Medicare, Medicaid and various private insurance plans. Your questions will be gladly answered regarding our participation with your insurance carrier. Payment of your medical/dental visit is expected at the time of service.