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:

  • Drop files here or

If you have any trouble uploading your patient documents, contact us with the button below.