Patient Forms

Sliding Fee Discount Application

Patient Satisfaction Survey – Medical, Dental, Behavioral Health, or Medical Case Management

Customer Satisfaction Survey – Supportive Services/Housing Programs

2019 HIV Prevention Interventions and Strategies Guidance

Acknowledgment of Privacy Notices

Patient Rights & Responsibilities

Consent to Treat

No Show & Late Cancellation Patient Notice

Patient Registration Form

Proxy consent form

Formas españolas

Christian Community Health Center delivers comprehensive primary medical and dental services that respond to the needs of the communities we serve.

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CCHC receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health related claims, including medical malpractice claims, for itself and its covered individuals. We have achieved NCQA Level 3 Patient Centered Medical Home recognition at all three clinic sites. We are IDHS-SUPR licensed to provide Level 1 and 2 outpatient substance use treatment services.

PATIENT FORMS

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