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