Digital Patient Forms
Complete your forms online before your visit to save time at check-in. Select the appropriate digital form, fill it out securely, and submit it electronically before your appointment.
Download Patient Forms, Notices, and Agreements
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.
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.
Designation of Healthcare Surrogate for a Minor
This form allows a parent or legal guardian to designate another trusted adult to make health care decisions for a minor child when needed.
Patient Information Release
This form authorizes CHCFL to release, request, or share a patient’s medical information with the individuals or organizations specified by the patient.
Financial Practice and Procedures
“Financial Practice and Procedures is a handout that answers patients’ questions regarding insurance responsibilities for services rendered.