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 patients

English | Spanish

New Patient Registration

Required for all patients

English | Spanish

Notice of Privacy Practice and Communication Preferences

Required for all 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

Affordable Healthcare

Healthcare Discount Information

2021 Sliding Fee Schedule

See how much of a healthcare discount you can get

English | Spanish

Healthcare Discount Forms

Healthcare 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.

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