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

• Family History Form

• Medical History Form

• Social History Form

• Medical Record Release Form

• Authorization for Consent to Medical Treatment for Minors

• HIPAA Notice of Privacy Practices

• Financial Policy

• Vaccine Philosophy

• Reference Laboratory Charges

• Consent to Use of Virtual Scribe

Se anima a los pacientes nuevos a completar los 6 formularios que figuran a continuación antes de acudir a la clínica para su primera visita.

• Papeles de historia familiar para nuevos pacientes

• Documentos de historia médica para nuevos pacientes

• Cuestionarios de antecedentes sociales para nuevos pacientes

• Autorización para usar o divulgar información de salud

• Permiso para tratar a menores

• Aviso de prácticas de privacidad de HIPAA

• Nuestra filosofía sobre las vacunas

• Consentimiento para el uso de un escriba virtual

• Cargos por servicios de laboratorio externo

• Registration form for COVID-19 vaccine

• Patient Portal Registration Form

To register for our online portal, please complete and return this form.

• NC High School Athletic Association Student Participation 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.)

• NC Kindergarten Assessment Physical Form

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.

• Application for NC Medicaid - English

To apply online, please go to: https://epass.nc.gov/

• NC Medicaid Application - Spanish

To apply online, go to: https://epass.nc.gov/

• Online Application for NC Medicaid (English and Spanish)

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.