Completing Your Forms Online
The forms portal is a secure page that gives patients convenient 24-hour access to submit many patient forms from anywhere with an Internet connection. Most forms are available for new and existing patients and take less than 5 minutes to complete.
- Available to New and Existing Patient Forms
- No Account or Setup Required
- Fast, Convenient, and Secure
New patients and existing patients that haven’t been seen by a Community Health Centers provider within the past 2 years are encouraged to complete the Patient Intake Form, and Telemedicine Consent form prior to their visit. The Sliding Discount Form should also be completed prior to your first visit for those who would like to see if they are eligible for financial assistance.
Download and Print Forms
All forms can also be downloaded and printed, to be completed offline and delivered in person. Most forms are offered in multiple languages for your convenience.
Community Health Centers is an accredited medical and dental home with the Accreditation Association for Ambulatory Health Care.
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 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 RequestThe 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 is the delivery of health services when the healthcare provider and patient are not in the same physical location through the use of technology.