Forms and Information

Below is a comprehensive list of forms and information you may be required to complete as a patient of Choptank Community Health System.

Still looking for something and can’t find it?

Contact our administrative offices at 410-479- 4306 and we would be happy to assist you!

New Medical Patient Forms

NEW PATIENT MEDICAL FORM ENGLISH

NEW PATIENT MEDICAL FORM SPANISH

NEW PATIENT MEDICAL FORM CREOLE

School-Based Enrollment Form

ENROLLMENT FORM (English, Spanish, Haitian Creole) | All School-Based Health Locations

HIPAA Notices

CCHS HIPAA NOTICE OF PRIVACY PRACTICES ENGLISH

CCHS HIPAA NOTICE OF PRIVACY PRACTICES SPANISH

CCHS HIPAA NOTICE OF PRIVACY PRACTICES CREOLE

Financial Forms

CONSENTS AND ASSIGNMENTS ENGLISH

CONSENTS AND ASSIGNMENTS SPANISH

PATIENT FINANCIAL RESPONSIBILITY FORM

PATIENT FINANCIAL RESPONSIBILITY FORM SPANISH

SLIDING FEE APPLICATION, AGREEMENT  AND ASSESSMENT ENGLISH

SLIDING FEE APPLICATION, AGREEMENT AND ASSESSMENT SPANISH

SLIDING FEE APPLICATION, AGREEMENT AND ASSESSMENT CREOLE