Patient Forms

New Patient Enrollment

If you are new to our clinic please complete the following:

Consent to Transport
Consent to Provide Care**
HIPAA Authorization to Release Confidential Medical Information**
Notice of Privacy Practices
Patient Portal Authorization Form**
Telehealth Informed Consent
Financial Responsibility (D5)**

**Not Optional/Required

Patient Privacy Notice

If you are new to our clinic please read over the CHCCC Notice of Privacy Practices. Know your rights as a patient. We encourage you to ask us any questions you have regarding this notice.

Financial Support Verification Form

If you are interested in our Sliding Discount Fee and are not currently employed and do NOT have insurance, please complete this form.

Sliding Fee Discount Program Application & Eligibility Form (D1)
No Income: Financial Support and Affirmation of Identity Form (D3)**

**Not Optional/Required

Questions?

If you have any immediate questions please call us at 620-221-3350.

If it is a question regarding the paperwork please leave it blank and ask our receptionist before your appointment.

Thank you and we look forward to seeing you!