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407-905-8827

Orange County

352-314-7400

Lake County

Forms Portal

Community Health Centers is an accredited medical and dental home with the Accreditation Association for Ambulatory Health Care.

Patient Forms

Community Health Centers has made it easier for first-time patients by offering health-related forms online. To complete the form(s) at your own pace, select the appropriate form(s), print them out, and bring them to your appointment completed. Please print them on white paper only.

Patient Intake Form

The Patient Intake Form is a complete set of forms to be filled out prior to your first visit.

Sliding Discount Program Application

The Sliding Scale Discount Program is part of Community Health Centers’ effort to provide essential services at lower costs for patients who are uninsured or underinsured. Complete this form prior to your appointment with a financial counselor.

Employment Verification

Employment verification is used by patients applying for the Sliding Discount Program, to help determine their eligibility. Complete prior to your appointment with a financial counselor.

Health Record Request

The Health Record Request Form is to be completed by patients who would like a copy of their health record from Community Health Centers.

Patient Authorization to Use or Disclose

The patient authorization to use or disclose form is used as a release of patient medical records, allowing Community Health Centers to utilize their past medical history to treat them.

Behavioral Health Consent

Behavioral Health providers have an opportunity to prevent healthcare disparities by working directly with patients’ Primary Care providers.

Patient Notices and Agreements

Telemedicine Consent

Telemedicine is the delivery of health services when the healthcare provider and patient are not in the same physical location through the use of technology.

Financial Practice and Procedures

“Financial Practice and Procedures is a handout that answers patients’ questions regarding insurance responsibilities for services rendered.

Notice of Privacy Practice

Patient Bill of Rights and Responsibilities – Advanced Directives

The Patient’s Right to Decide

4.7

4.7/5

70,000+ Healthy Patients
Rating calculated using an average of internal patient surveys across all locations.

To protect your privacy, please refrain from providing personal health information or any other sensitive information via contact form. A patient service rep will contact you and request the needed information.

Orange County

Lake County