New Patient Enrollment Request

Community Health Network will exempt you from all Covid-19 Telehealth and Testing cost if you provide your insurance information.

If you do not have insurance information, we need your social security number, driver's license number and citizenship status to recover our costs through Health and Human Services.

If you are uninsured and do not have a social security number or drivers license number, please request a Patient Eligibility appointment. Community Health Network will accommodate your need for Covid-19 services.

Please provide the following information to enroll as a new patient with Community Health Network.

Desired Service Type

How did you hear about us?

Referred By

Patient First Name

Middle

Last/Family Name

Nickname

Birthdate

Birth Gender

Gender Identity

Marital Status

Race

Ethnicity

US Citizen

Social Security

Driver License

Street Address

City

State

Postal Code

County of Residence

Primary Phone

Phone Type

Email Address

Emergency Contact

Emergency Phone

Relaionship

Language

Okay to Contact

Preferred Contact

Primary Insurance

Effective Date

Subscriber Type

Subscriber First Name

Middle

Last/Family Name

Group Number

Policy Number

CoPay Amount

Insurance Address

Attention/Contact

City

State

Postal Code

Contact Phone

Employment Status

Occupation

Employer Name

Employer Address

Employer City

Employer State

Postal Code

Employer County

Financial Information

Family Size (including patient)

Total Monthly Income

Special Situations

Homeless Status

Public Housing

Migrant/Seasonal

Veteran Status

Patient full name below to digitally sign this form:

Date Signed

Guardian Full Name

Relaionship to Patient

I acknowledge that I am the parent or legal guardian of this patient and can make decisions concerning health care services for this individual.

Community Health NetworkNew Patient Enrollment

Financial Information

Special Situations

Community Health Network
New Patient Enrollment