Community Health Centers 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.
- Sliding Discount Program Application – The sliding discount program is part of CHC’s effort to provide essential services. Complete prior to your appointment with a financial counselor.
Sliding Discount Program Application Form
Sliding Discount Program Brochure – English
Sliding Discount Program Brochure – Spanish
- 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.
Employment Verification Form – English
Employment Verification Form – Spanish
- Patient Authorization to Use or Disclose – The patient authorization to use or disclose form is used as a release of a patients medical records, allowing CHC to utilize their past medical history to treat them.
Patient Authorization to Use or Disclose – English
Patient Authorization to Use or Disclose – Spanish
Patient Authorization to Use or Disclose – Creole
- Health Record Release – For patients who want a copy of their health records from CHC.
Authorization to Disclose Health Information – English
Authorization to Disclose Health Information – Spanish
Authorization to Disclose Health Information – Creole