Forms
Please be sure to have your child's immunization records sent to our office prior to your child's first visit here, or you can bring them with you to the visit.
Asegúrese de enviar los registros de vacunación de su hijo a nuestra oficina antes de la primera visita de su hijo aquí, o asegúrese de llevarlos con usted a la visita.
Patient Forms
New patients are invited to fill out the 6 forms listed below before they come into the clinic for their first visit. Records Release forms can be emailed to us at: frontdesk@chcc.pcc.com
Paperwork for New Patients
New patients are encouraged to complete the 6 forms below before coming to the clinic for their first visit.
Additional Office Forms
To register for our online portal, please complete and return this form.
If your child is participating in school sports in middle or high school, please print out this form. (We will need you and your child to complete your section before we can complete ours.)
If your child is going to kindergarten this upcoming school year, please print a copy of this form, complete its section, and bring to your child's upcoming physical appointment.
Applications for NC Medicaid
To apply online, please go to: https://epass.nc.gov/
To apply online, go to: https://epass.nc.gov/
Good Faith Estimate
Your Right to a Good Faith Estimate
Under the law, healthcare providers must give patients who don't have insurance or are not using insurance an estimate of the bill for medical items and services. This is called a Good Faith Estimate.
You have the right to receive a Good Faith Estimate and we will provide one upon request. The Good Faith Estimate shows the total expected cost of any non-emergency items or services, including medical tests, supplies, and other fees. This estimate is based on information known when the estimate was created and will include costs.
You may request a Good Faith Estimate in advance of an already scheduled medical service or item, or before scheduling an item or service. The estimate will be provided within three days of request and within one business day of a previously scheduled service.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. It also does not include services or treatment provided by outside laboratory services. You could be charged more if complications or special circumstances occur.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit
www.cms.gov/nosurprises .
Request a Good Faith Estimate
The fastest way to receive an estimate is through your portal account. If you do not have a portal account, please call us to request one.
You may also request an estimate by phone at 919-967-0771.
Estimates may also be provided by mail or email.
latest news
You may have heard news about rising numbers of measles cases in Texas and other areas of the United States. 2 doses of the MMR vaccine are highly effective (97%) at preventing measles infections. At CHCAC, children receive their first dose at age 1 and a second dose at age 4, to make sure kids are fully protected as soon as possible, and following the recommendations from the CDC. Some infants aged 6 months to 11 months who travel internationally to high-prevlance areas may need a dose to protect them, but they still need the 1 year and 4 year old doses as well. If you are ever concerned about a possible exposure to measles, please CALL before entering our office. DO NOT ENTER the office. This is a highly contagious illness and special precautions must be taken to prevent spread.
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latest news