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