Patient Forms

Patient Forms

The following forms have been provided for your convenience. To complete the required paperwork, please click on the form below, download, complete, and return. If you have any questions, please reach out to a Patient Services Representative by calling 610-326-9460

New Patient Forms

New Patient Registration Packet

Required for all patients

English | Spanish

New Patient Health History

Required for all medical patients

English | Spanish

New Patient Dental Health History

Required for all new dental patients

English | Spanish

HIPAA Permissions

HIPAA Release of Medical Information - Transfer In

Only required if you want to transfer records in to CHDC

English | Spanish

HIPAA Release of Medical Information - Transfer Out

Only required if you want to transfer records out of CHDC

English | Spanish

HIPAA Release - Personal Health Record Request

Only required if you want to receive a copy of your personal health records

English | Spanish

Consent to Treatment (New Form)

HIPAA Privacy Notice and Communications Preference Forms are required to be updated yearly or when there is a change of information

English | Spanish

Patient Notice of Privacy Practices

Health Information Privacy Notice Brochure

English | Spanish

Affordable Healthcare

Healthcare Discount Information

Healthcare Discount Information

Information and FAQ

English | Spanish

2023 Sliding Fee Schedule

See how much of a healthcare discount you can get

English | Spanish

Healthcare Discount Forms

Healthcare Discount Application

Apply for your Healthcare Discount

English Spanish

Self-Declaration of Income & Housing Form

Figure out what discount you get

English | Spanish

Self-Employment Form

For self-employed individuals

English | Spanish

To submit your completed forms, please send an email to patientforms@ch-dc.org or click the button below.

CHDC Billing Text To Pay:

  • Payment reminder texts began on 1/8/2024
  • Reminder text will be sent out BEFORE billing statement
  • Texts are coming from (888) 695-7386
  • Link to pay included with the text

To submit your completed forms, please send an email to patientforms@ch-dc.org or click the "Submit Patient Forms" button above.