Notice of Privacy Practice

 

Notice of Privacy Practice
Required for all patients

HIPAA Receipt of Privacy Notice
Required for all patients

HIPAA Permissions

 

HIPAA Authorization for a Minor
Only required if you want someone else to authorize care for your child (children)

HIPAA Restrictions Form
Only required if you want to place restrictions on your medical records

HIPAA Release of Medical Information
Only required if you want to transfer records into or out of CHDC

HIPAA CHDC Complaint Form
Complaint form to be filed with our company

Heathcare Discount Schedule

 

2019 Sliding Fee Schedule

Financial Assistance Program Details

 

Healthcare Discount Information

Please submit your forms using the form below

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CARING FOR THE COMMUNITY

Community Health and Dental Care is committed to providing affordable, accessible, quality care for everyone in our community. In order to succeed in our mission, we rely on collaborated efforts from many organizations within our community.