Patient Intake App
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Patient Intake Forms
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Patient Intake Forms

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CHC New Patient Registration Form
Patient Details
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Please enter your email address
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ext.
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If you have any questions related to the fields below, please call (860) 347-6971 to register.
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Social Determinants of Health (SDoH)
If you are looking for support, please complete the following set of questions so that we can determine how to best support you.
If you would like help with food, housing, insurance, transportation or other needs, you can contact 211 by dialing 211 from a phone or by visiting www.211ct.org.
Guarantor Information
 
The Guarantor is the person who should be sent billing statements.
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Please enter your email address
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Emergency Contact Details
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Insurance Information
Please review the following documents
Please click on the Terms and Conditions. to review our policies regarding your personal health information

By checking the box below, I acknowledge that I have read the above documents and received a copy of the Terms and Conditions.
 
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Please click on the CHC s Notice of Privacy Practices (NPP). to review our policies regarding your personal health information

By checking the box below, I acknowledge that I have read the above documents and received a copy of CHC s Notice of Privacy Practices (NPP).
 
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Please click on the Consent to treament. to review our policies regarding your personal health information

By checking the box below, I acknowledge that I have read the above documents and received a copy of the Consent to treament.
 
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Former/Current Healthcare Provider Info
CHC would like to collect your previous medical history and information. By completing an ROI (a Release of Information) below, you may authorize CHC to OBTAIN your info from your previous healthcare office
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ext.
ext.
Submit
Release Signature
I understand that I have a legal right to revoke this authorization at any time/ I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Community Health Center, Inc. (CHC) Medical Records Department. I understand that the revocation will not apply to information that has already been released in response to his authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations.

I understand authorizing the use or disclosure of the information identified is voluntary. I can refuse to sign this authorization. I need not sign this form to ensure healthcare treatment. I can contact the Privacy Officer if I have questions about my health information.

I understand that by entering my name below, I am signing this Authorization electronically. I agree that my electronic signature is the legal equivalent of a manual signature on this Authorization.
By signing below, I acknowledge that I have read and understand this authorization form and that CHC has 30 days to fulfill my request.
 
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Can I annotate fields to indicate their intended use?

Yes. You can provide "Help" to your users for any field:

1. On any page in your application, click "Customize" then "Fields". If it is a multi-table application, select the table.

2. Click the "Edit" button next to the field for which you want to add an annotation.

3. In the "Help" text input box, enter text that will assist your users, and click "Save".

Your text will appear when the user hovers over or clicks on the question mark icon next to that field on the Add Record and Edit Record pages.
 
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You've made changes to this Patient. Do you want to save these changes before going to the next screen?
Report Name *
Description
Reports and Charts Panel
Each table has a panel listing its reports and charts, organized in groups.
Please wait while your new report is saved...
Print the report as a table
Print one Patient per page ( total)
Using the form:
Print as much of the timeline as fits on a single page
Print the timeline over multiple letter-size pages in landscape orientation
  • New subscription...
  • Print
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    Column properties... Field properties...
    grouping by
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    What does auto mean?
      Multiple values found.   more...
    Fields in:

    Fields to Extract:

    Name for the new table:
    Items in the new table are called:

    When you bring additional fields into a conversion, Quickbase often finds inconsistencies. For example, say you're converting your Companies column into its own table. One company, Acme Corporation, has offices in New York, Dallas and Portland. So, when you add the City column to the conversion, Quickbase finds three different locations for Acme. A single value in the column you're converting can only match one value in any additional field. Quickbase needs you to clean up the extra cities before it can create your new table. To do so, you have one of two choices:

    • If you want to create three separate Acme records (Acme-New York, Acme-Dallas and Acme-Portland) click the Conform link at the top of the column.
    • If the dissimilar entries are mistakes (say Acme only has one office in New York and the other locations are data-entry errors) go back into your table and correct the inconsistencies—in this case, changing all locations to New York. Then try the conversion again.

    Read more about converting a column into a table.


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