New Patient On-Boarding
Patient Forms
Privacy Practice
Notice of Privacy Practice
Required for all patients
HIPAA Receipt of Privacy Notice
Required for all patients
HIPAA Permissions
HIPPA Authorization for a Minor
Only required if you want someone else to authorize care for your child (children)
HIPAA Release of Medical Information
Only required if you want to transfer records into or out of CHDC
HIPAA Restrictions Form
Only required if you want to place restrictions on your medical records
HIPAA CHDC Complaint Form
Complaint form to be filed with our company
Affordable Healthcare
Healthcare Discount Information
2019 Sliding Fee Schedule
See how much of a healthcare discount you can get
Financial Assistance Program
Learn about our affordable healthcare program
Healthcare Discount Forms
Healthcare Application
Apply for Your Healthcare Discount
Income & Housing Declaration
Figure Out What Discount You Get
Self-Employment Form
For self-employed individuals
Please submit your documents using the form below:
If you have any trouble uploading your patient documents, contact us with the button below.