PATIENT FORMS

Patient Forms

Please note: Effective July 1, 2020, the CHDC Fee Schedule has changed.  A copy of the Fee Schedule is available upon request by sending an email to info@ch-dc.org.  Thank you.

New Patient Forms

New Patient Health History

Required for all patients

New Patient Registration

Required for all patients

Notice of Privacy Practice and Communication Preferences

Required for all patients

HIPAA Permissions

HIPAA Release of Medical Information - Transfer In

Only required if you want to transfer records in to CHDC

HIPAA Release of Medical Information - Transfer Out

Only required if you want to transfer records out of CHDC

HIPAA Release - Personal Health Record Request

Only required if you want to receive a copy of your personal health records

Affordable Healthcare

Healthcare Discount Information

2020 Sliding Fee Schedule

See how much of a healthcare discount you can get

Healthcare Discount Forms

Healthcare Application

Apply for Your Healthcare Discount

Self Declaration of Income & Housing Form

Figure Out What Discount You Get

Self-Employment Form

For self-employed individuals

To submit your completed forms, please CLICK HERE.