Patient Portal


 

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Patient Portal | Community Health and Dental Care



Registration Forms

Medical Registration Form
Required for all patients

Medical Registration Form (en español)
Required for all patients

HIPAA – Patient Consent Form
Required for all patients

Dental History

Dental Health History Form

Medical History

Medical History

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/2017 Sliding Fee Schedule

2017 Sliding Fee Schedule

Financial Assistance Program Details

Healthcare Discount Information

Healthcare Discount Forms

Healthcare Application

Self-Declaration of Income and Housing Form

Self-Employment Form

 

English Version

Spanish Version