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