Please find the applicable form below. You can either “Download” or “Preview” by clicking the respective link/button.
To complete a form:
- Click “Download” and save the document to your local hard drive computer/device.
- Open the document from the location you saved it in using a free .pdf reader like Adobe Acrobat Reader.
- A light purple field indicates that it is fillable. Click each field and enter your information.
- Print the file.
- Bring the forms to the health center for your next appointment.
| Title | Description | Download |
|---|---|---|
| Authorization for Care of Minor | Authorization for SCHC to provide care for your minor child. Also, authorizes other named adults to seek treatment for your child if indicated. | DownloadPreview |
| Authorization to Release Information to Anyone | Authorization to allow friends or family members to call and request results of tests, procedures and financial information about you. | DownloadPreview |
| CDL.DOT-MedicalExamReportForm- | Commercial driver medical examination report form. | DownloadPreview |
| CDL.DOTMedicalExamCertificate | Commercial driver's medical examiner's certificate form. | DownloadPreview |
| Dental Health History | Dental health history form for all aged patients. | DownloadPreview |
| Grievance / Complaint Form | A formal expression of dissatisfaction with some aspect of care or service that has not been resolved to the patient/family’s satisfaction at the point of service. | DownloadPreview |
| Health History Adult | Health history form for adults. | DownloadPreview |
| Health History Pediatric Care | Health history form for children.
| DownloadPreview |
| Notice of Privacy Practices Acknowledgement | Acknowledgment and consent of SCHC's Notice of Privacy Practices. | DownloadPreview |
| Patient Financial Responsibility | Patient's acceptance of financial responsibility for services received. | DownloadPreview |
| Patient Information-Profile | New patient registration. Also applies to patients that have not received care at at SCHC for over 1 year. | DownloadPreview |
| Permission for Family Access to PHI | DownloadPreview | |
| Release of Information | Authorization for SCHC to receive your information from another medical provider or to send your information to another medical provider. | DownloadPreview |
| Slide Eligibility Application | Application for discount fee, based on income. Must be submitted to SCHC 48 hours BEFORE appointment. | DownloadPreview |
| Substance Use Form | Substance use assesment and history. | DownloadPreview |