Patient Forms
Select a Tab to Find a Your Form(s)
- New Patient Packet This completed packet needs to be returned back to Clinch River Health Services one week prior to your first appointment.
- NEW PATIENT INFORMATION- BEHAVIORAL HEALTH
- New Patient Packet (Spanish Version)
- Patient Registration Form
- Patient Registration (Spanish Version)
- General Consent Form
- Behavioral Health Consent Form
- General Consent Form (Spanish Version)
- Authorization for Use Disclosure Personal Health Information
- Authorization for Use Disclosure Personal Health Information (Spanish Version)
- Patient Rights and Responsibilities
- Patient Rights and Responsibilities (Spanish Version)
Other Forms:
Financial Assistance
Clinch River Health Services is a community health center serving those with and without health insurance. It is not, however, a free clinic. All of our patients are expected to pay a portion of the care they receive.
For those who are uninsured or under-insured, we offer a sliding-fee scale based on household income and family size. Our pharmacy also offers medication assistance.
Even if you have insurance, you may qualify to be on our sliding scale if your family income is less than 200% of the Federal Poverty Level.
- Sliding Fee Eligibility Form
- Sliding Fee Eligibility Form (Spanish Version)
- Sliding Fee DSS Benefits Release Form
- Sliding Fee Self Declaration of Income Form
- Sliding Fee Self Employed Proof of Income Form
- 2023 Sliding Fee Schedule
- 2023 Sliding Fee Schedule (Spanish Version)
- 2023 Sliding Fee Discount Program
- 2023 Sliding Fee Discount Program (Spanish Version)
Our Hours:
- Monday: 8:30 a.m.- 8 p.m.
- Tuesday: 10:45 a.m.- 5 p.m.
- Wednesday: 8:30 a.m.- 5 p.m.
- Thursday: 8:30 a.m.- 8 p.m.
- Friday: 8:30 a.m.- 5 p.m.
- Saturday: 8:30 a.m.- 12 Noon