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
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
Healthcare Discount Forms
Once your forms are completed, please contact us at 610-326-9460 to speak with a member of our Patient Services team.
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
Once your forms are completed, please contact us at 610-326-9460 to speak with a member of our Patient Services team.