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 Medical Form

Required for all patients

New Patient Non-Medical Form

Required for all patients

Privacy Practice

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.