Patient Centered Medical / Dental Home
A Patient Centered Medical/Dental Home is called a “home” because we would like it to be the first place you think of for all your healthcare needs. Much like a home, our goal is to make it easy and comfortable for you to get the care you need in a way that works best for you. Within our home, a partnership develops between you and your Care Team: the providers, clinical support, and office staff dedicated to coordinating the services you need for the best care possible. The focus is on you.
YOUR PRIMARY CARE PROVIDER PLEDGES TO
- Coordinate your care across all settings (for example specialists, rehabilitation centers, behavioral health).
- Be available to you during and after regular business hours for your care needs.
- Explain diseases, treatments, and results in an easy-to-understand way.
- Learn all about you, your history, your care preferences, and your health goals.
- Keep treatments, discussions, and records private.
- Provide instructions on how to meet your healthcare needs after hours.
- Give you clear directions about treatments and medications.
- Listen to your questions and concerns to help you make decisions about your care.
- Provide optimal care based on nationally researched clinical protocols.
- Communicate in a timely fashion test results, information about alternative services to help you maintain a healthy lifestyle, and updates on vaccines and screenings.
- End every visit with clear instructions about expectations, treatments, and future plans.
Community Health Centers is an accredited medical and dental home with the Accreditation Association for Ambulatory Health Care.
DOWNLOAD OUR BROCHURE
Community Health Centers have 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.
- Patient Intake Forms – The Patient Intake Form is a complete set of forms to be filled out prior to the first visit.
Patient Intake Form – English
Patient Intake Form – Spanish
- 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 patient 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
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.
Telemedicine Consent – English
Telemedicine Consent – Spanish
Telemedicine Consent – Creole
- Medical / Dental Home Welcome Booklet – The Medical / Dental Home Welcome Book is a complete guide on what to expect as a CHC patient. Learn more about us, find out how to schedule appointments, payments, changing providers are more.
Welcome Book – English
Welcome Book – Spanish
Welcome Book – Creole
- Financial Practice and Procedures – Get answers to questions regarding patient and insurance responsibilities for services rendered.
Financial Practice and Procedures – English
Financial Practice and Procedures – Spanish
Financial Practice and Procedures – Creole
- Notice of Privacy Practice
Privacy Practices – English
Privacy Practices – Spanish
Privacy Practices – Creole
- Patient Bill of Rights & Responsibilities – Advanced Directives
Bill of Rights – English
Bill of Rights – Spanish
Bill of Rights – Creole
- The Patient’s Right to Decide
The Patient’s Right to Decide – English
The Patient’s Right to Decide – Spanish
The Patient’s Right to Decide – Creole
To help better serve our patient’s needs, we now offer same-day access at limited locations.
Contact us at (407) 905-8827 to make an appointment or walk-in to your participating center. For faster service please bring a photo ID, insurance card (if applicable), copay, list of medications you’re currently taking, and any medical records that you may have.
If you wish to apply for our sliding discount program, please call our appointment line and set up an appointment with one of our friendly staff members that will assist you with the eligibility process.
Items to bring to your first visit
- Photo identification
- Health insurance card(s)
- Social Security card
- Proof of income for sliding scale fee schedule discount
- Medical or dental history
- Medical records (especially) if recent hospital admission or emergency room visit
- All medications currently taking
- Foster parent or grandparent: Guardian or custody papers showing custody of child required
- Adult guardian: Power of Attorney
We accept most types of insurance plans, including Medicare, Medicaid, HMOs, PPOs, KidCare, Medikids, Healthy Kids, Children’s Medical Services (CMS), and other plans. Please call to ensure that your insurance is among those we accept.
- Payment is expected on the day services are provided.
- Co-pays or the nominal fees are collected at check-in. At check-out, additional fees may be due based on the services you received.
- You are encouraged to apply for our sliding scale program. If eligible, the program may reduce costs for the uninsured or be applied to insurance deductibles and co-insurances.
- We serve all patients regardless of their ability to pay.
If you need financial assistance, please schedule an appointment to speak with one of our financial counselors to make arrangements.
Providers are available for after-hours emergency calls through our answering service at 407-905-8827. In the event of an emergency, please call 911.