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.
Request an Appointment Online
The Request an Appointment form can be used by new or existing patients, to request a medical or specialty services appointment. After submission, a Patient Intake Representative will reach out to confirm your appointment.
New patients can complete the Patient Intake form ahead of time online or in-person the day of their appointment.
Patient Intake Form
The Patient Intake form is for new patients or patients that have not been seen by a provider in more than two years and is expected to take ten minutes to complete. You will need to complete our Patient Intake Form before your first appointment.
Prefer to print and complete offline? Download PDF
Sliding Discount Program Application
Our Sliding Discount Program reduces the cost of care to our uninsured patients based on their income and family size. Patients with insurance may also benefit from this program.
Discounts are offered depending upon household income and size. A “Family” is one or more persons living in one dwelling place who are related by blood, marriage, or law. Adults and minor children are considered a family. Relatives over 18 (that are not full-time students) are not eligible to be used as dependents for this application process.
If you are not a patient or have not seen a CHC provider, you’re encouraged to submit a Request Appointment and Patient Intake Form first.
Prefer to print and complete offline? Download PDF
Telemedicine Consent Form
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. Provider may include primary care practitioners, specialists, behavioral health providers, and/or subspecialists.
Electronically-transmitted information may be used for diagnosis, therapy, follow-up, and/or patient education, and may include any of the following: Patient medical records, medical images, Interactive audio, video, and/or data communications, Output data from medical devices, and sound and video files. Patients must be in the state of Florida in order to use Telemedicine.
Prefer to print and complete offline? Download PDF
Behavioral Health Consent Form
Community Health Centers behavioral health specialists, including Psychiatrists and Licensed Clinical Social Workers (LCSW), provide affordable treatment for a variety of conditions, from mental health-related to medical concerns. We are able to develop strategies to enhance the quality of care provided and improve treatment outcomes.
Prefer to print and complete offline? Download PDF
Request Your Medical Records Online
The Health Record Request Form allows you to request a copy of your records and identify where you would like them sent. You will also be able to choose how you would like to receive them, electronic or mailed.
NOTE: Pickup in person is currently unavailable. If this selection is made, we will contact you to help choose another method. Share Health Data Services has not been authorized to accept any subpoenas or other legal process for any clients served by Share Health Data Services. All subpoenas and/or legal process documents must be served directly on the party from whom disclosure of records is being sought.
Prefer to print and complete offline? Download PDF
Surrogate Access for Healthcare Decisions
The Designation of Health Care Surrogate for a Minor is to allow parents/legal guardian/legal custodians the ability to name a surrogate(s) to take part in the health decisions for a minor. Prefer to print and complete offline? Download PDFPatient Information Release Consent
The Patient Information Release Consent notice describes how Community Health Centers, Inc. may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information. Prefer to print and complete offline? Download PDFCommunity 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.