Community Health Network
New Patient Enrollment
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
-- select --
Women`s Health Services
Men`s Health Services
Pediatric Health Services
Dental Health Services
Mental / Behavioral Health
Immunization Services
General Health Services
Covid-19 Consultation
Covid-19 Testing
Seasonal Flu Shot
Event Registration
Other Service Not Listed
How did you hear about us?
--select--
Newsletter or Flyer
Social Media
Magazine
Event
Word of Mouth
CHN
Other
Referred By
Patient First Name
Middle
Last/Family Name
Nickname
Birthdate
Birth Gender
-- select --
Female
Male
Gender Identity
-- select --
Male
Female
Transgender Male / Female-to-Male
Transgender Female / Male-to-Female
Other
Chose not to disclose
Marital Status
--select--
Married
Single
Divorced
Widowed
Separated
Domestic Partner
Unknown
Race
--select--
Declined To Specify
American Indian or Alaska Native
Asian
Black or African American
White
Native Hawaiian
Other Pacific Islander
More than one race
Ethnicity
--select--
Hispanic or Latino
Not Hispanic or Latino
Unreported / Refused to Report Ethnicity
US Citizen
--select--
Yes
No
Social Security
Driver License
Street Address
City
State
--select--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code
County of Residence
--select--
Anderson
Andrews
Angelina
Aransas
Archer
Armstrong
Atascosa
Austin
Bailey
Bandera
Bastrop
Baylor
Bee
Bell
Bexar
Blanco
Borden
Bosque
Bowie
Brazoria
Brazos
Brewster
Briscoe
Brooks
Brown
Burleson
Burnet
Caldwell
Calhoun
Callahan
Cameron
Camp
Carson
Cass
Castro
Chambers
Cherokee
Childress
Clay
Cochran
Coke
Coleman
Collin
Collingsworth
Colorado
Comal
Comanche
Concho
Cooke
Coryell
Cottle
Crane
Crockett
Crosby
Culberson
Dallam
Dallas
Dawson
Deaf Smith
Delta
Denton
DeWitt
Dickens
Dimmit
Donley
Duval
Eastland
Ector
Edwards
Ellis
El Paso
Erath
Falls
Fannin
Fayette
Fisher
Floyd
Foard
Fort Bend
Franklin
Freestone
Frio
Gaines
Galveston
Garza
Gillespie
Glasscock
Goliad
Gonzales
Gray
Grayson
Gregg
Grimes
Guadalupe
Hale
Hall
Hamilton
Hansford
Hardeman
Hardin
Harris
Harrison
Hartley
Haskell
Hays
Hemphill
Henderson
Hidalgo
Hill
Hockley
Hood
Hopkins
Houston
Howard
Hudspeth
Hunt
Hutchinson
Irion
Jack
Jackson
Jasper
Jeff Davis
Jefferson
Jim Hogg
Jim Wells
Johnson
Jones
Karnes
Kaufman
Kendall
Kenedy
Kent
Kerr
Kimble
King
Kinney
Kleberg
Knox
Lamar
Lamb
Lampasas
LaSalle
Lavaca
Lee
Leon
Liberty
Limestone
Lipscomb
Live Oak
Llano
Loving
Lubbock
Lynn
Madison
Marion
Martin
Mason
Matagorda
Maverick
McCulloch
McLennan
McMullen
Medina
Menard
Midland
Milam
Mills
Mitchell
Montague
Montgomery
Moore
Morris
Motley
Nacogdoches
Navarro
Newton
Nolan
Nueces
Ochiltree
Oldham
Orange
Palo Pinto
Panola
Parker
Parmer
Pecos
Polk
Potter
Presidio
Rains
Randall
Reagan
Real
Red River
Reeves
Refugio
Roberts
Robertson
Rockwall
Runnels
Rusk
Sabine
San Augustine
San Jacinto
San Patricio
San Saba
Schleicher
Scurry
Shackelford
Shelby
Sherman
Smith
Somervell
Starr
Stephens
Sterling
Stonewall
Sutton
Swisher
Tarrant
Taylor
Terrell
Terry
Throckmorton
Titus
Tom Green
Travis
Trinity
Tyler
Upshur
Upton
Uvalde
Val Verde
Van Zandt
Victoria
Walker
Waller
Ward
Washington
Webb
Wharton
Wheeler
Wichita
Wilbarger
Willacy
Williamson
Wilson
Winkler
Wise
Wood
Yoakum
Young
Zapata
Zavala
Not Listed
Primary Phone
Phone Type
--select--
Mobile Phone
Work Phone
Home Land Line
Email Address
Emergency Contact
Emergency Phone
Relaionship
--select--
Self
Spouse
Mother
Father
Sibling
Guardian
Custodian
Grand Parent
Step Parent
Foster Parent
Other Family
Other Non-Family
Language
--select--
English
Spanish
Okay to Contact
--select--
NO
YES
Preferred Contact
--select--
Cell Phone
SMS Text
Patient Portal
Email Message
No Preferrence
Primary Insurance
--select--
NO INSURANCE
INSURANCE COMPANY NOT LISTED
90 DEGREE BENEFITS
AARP MEDICARE ADVANTAGE
AARP MEDICARE COMPLETE
AARP SUPPLEMENT PLAN F
ABMS USA, INC (PAPER)
ACC (ALVIN COMMUNITY COLLEGE)
ACI FIRST HEALTH
ADMINISTRATIVE CONCEPTS, INC
AETNA (KELSEY) * OON
AETNA BETTER HEALTH *
AETNA CHIP
AETNA INS. COMPANY
AETNA MEDICARE
AETNA MEDPREMIER
AGENTRA - HMA
AISD STUDENT
ALIERA HEALTHCARE UNITY
ALL SAVERS (UHC)
ALLEGIANCE BENEFIT PLAN
ALLIANCE HEALTH AND LIFE (CIGNA)
ALLIED BENEFITS SYSTEMS, INC
AMBETTER SUPERIOR HEALTHPLAN
AMERICAN FAMILY LIFE ASSURANCE CO
AMERICAN FINANCIAL SECURITY (PAPER
AMERICAN NATIONAL (ANICO)***
AMERICAN WORKER FIRST HEALTH
AMERICARES
AMERIGROUP CHIP
AMERIGROUP CHIP PERINATE
AMERIGROUP MEDICAID
AMERIGROUP MEDICARE AMERIVANTAGE
AMERIGROUP MEDICARE AMV SELECT(HMO
AMERIGROUP MEDICARE CLASSIC (HMO)
APWU HEALTH PLAN (CIGNA HEALTHCAR
ASSURANT HEALTH
BAKER ADMINISTRATIVE BENEFITS /PHS
BCBS MEDICAID
BEACON
BEACON (CHIP)
BEACON HEALTH OPTIONS (VALUE)
BEHAVIORAL HEALTH SYSTEMS
BENEFIT ADMINISTRATIVE SERVICES, L
BENEFIT ADMINISTRATIVE SYSTEMS, LL
BENVEO/ UCS
BIND
BLUE CROSS BLUE SHIELD (PPO)
BLUE CROSS BLUE SHIELD HMO
BMA
BOON ADMINISTRATIVE SERVICES
BOON ALLIED UNIVERSAL
BOON-CHAPMAN
BRAZOS PLACE
CAPITOL ADMINISTRATORS FIRST HEALT
CARE IMPROVEMENT PLUS
CDBG
CENPATICO
CENTRAL UNITED LIFE (PAPER)
CENTURY HEALTHCARE MULTIPLAN
CHAMP VA
CHARITY
CHRISTIAN CARE MINISTRIES (MEDISHA
CIGNA (KELSEY) * OON
CIGNA HEALTH INSURANCE
CIGNA-HEALTHSPRING (MEDICARE)*
COLONIAL PENN (PAPER)
COMM HEALTH CHOICE CHIP PERINATAL
COMMUNITY FIRST HEALTH PLANS*
COMMUNITY HEALTH CHOICE
COMMUNITY HEALTH CHOICE CHIP
COMMUNITY HEALTH CHOICE MARKETPLAC
COMPSYCH
CONCORDIA CARE RISK
CONTINENTAL BENEFITS (PAPER)
CONTINENTAL HEALTH
COOK CHILDREN`S HEALTH PLAN
CORESOURCE
CORNERSTONE
COVID-19 UNINSURED PROGRAM
CSI
DEVOTED HEALTH, INC
DIVERSIFIED ADMIN CORP
DRISCOLL (OUT OF NETWORK)
EBA & M CORPORATION (PAPER)
EBA & M CORPORATION - FIRST HEALTH
ECHO HEALTH
EMPLOYER PLAN SERVICES
ENTRUST
ENTRUST INC.
ESSENTIAL STAFFCARE
FAMILY PLANNING
FIRST HEALTH - PAI
FIRST HEALTH NETWORK
FIRST HEALTH NETWORK/MULTIPLAN
FREEDOM LIFE
FRINGE BENEFIT GROUP
FULL PAY
GILSBAR LLC
GOLDEN RULE INSURANCE COMPANY(UHC)
GPA
HARTFORD WEBTPA
HEADSTART
HEALTH ALLIANCE PLAN
HEALTH CARE SOLUTIONS
HEALTH FIRST
HEALTH PARTNERS
HEALTH PLANS, INC.
HEALTH SMART
HEALTH WEST ADMINISTRATORS
HEALTHCARE MANAGEMENT ADMIN
HEALTHCARE SOLUTIONS GROUP
HEALTHGRAM
HEALTHGRAM
HEALTHWEST ADMINISTRATORS
HEALTHY TEXAS WOMAN
HEIDI E BOUDERBA
HM ARMA
HM-OXFORD HEALTH PLAN
HMA LLC
HORIZON BCBS NJ
HORIZON BCBS NJ (BH)
HUMANA
HUMANA MEDICARE
HUMANA MEDICARE HMO
HURRICANE HARVEY PATIENT
IMA, INC.
IMPACT HEALTH - MULTIPLAN
INSURANCE BENEFIT SYSTEM ADMIN
INSURANCE BSA C/O ZELIS
INTERNATIONAL BENEFITS ADMINSTRATO
IRON ROAD HEALTHCARE
JIM ADLER & ASSOCIATES
KELSEY SEYBOLD * OUT OF NETWORK
KELSEYCARE MEDICARE
KEY BENEFIT ADMIN (KBA)
KEY SOLUTIONS PLAN (MULTIPLAN)
KEYSTONE HEALTH EAST
LA BCBS HEALTH SERVICE
LESLIE
LESLIE DE LA FUENTE
LIBERTY HEALTHSHARE*
LINECO BENEFIT FUND
LOYAL AMERICAN
MAGELLAN
MAYO MEDICAL PLAN
MEDI-SHARE
MEDICARE
MEDICARE/MEDICAID DUAL [MQMB]
MEDICARE/MEDICAID [QMB]
MEDICO CORP
MEMORIAL HERMANN * OUT OF NETWORK
MERITAIN HEALTH
MOLINA CHIP PERINATE
MOLINA MARKETPLACE
MOLINA MEDICARE MMP
MOLINA MEDICARE OPTIONS PLUS
MOLINA OF TX CHIP
MOLINA OF TX MEDICAID
MSC CLASSIC CARE MEDICARE ADVANTAG
MUTUAL OF OMAHA
NALC HEALTH BENEFIT PLAN
NALC HEALTH BENEFIT PLAN (2ND)
NATIONAL ASSOCIATION OF LCHBP
NATIONAL ELEVATOR INDUSTRY HBP
NATIONAL GENERAL
NETWORK TO CARE - HM
NEW ERA LIFE INSURANCE
OMAHA SUPPLEMENTAL INS CO
OPTUM
OPTUM (CHIP)
OPTUM (MEDICARE)
OPTUM (PRIVATE)
OPTUM HEALTH BEHAVIORAL SOLUTIONS
OSCAR (OUT OF NETWORK)
PAN-AMERICAN
PARKLAND COMM HEALTH PLAN *
PHC
PHCS
PHCS
PHILADELPHIA AMERICAN LIFE INS. CO
POINT COMFORT UNDERWRITERS
PPC PATIENT PHYSICIAN COOPERATIVES
PRESBYTERIAN HEALTH PLAN
PRESUMPTIVE HTW
PRESUMPTIVE MEDICAID
PREVENTATIVE WOMEN SERVICES - HM
PRO ACT, INC
PURTIAN LIFE INSURANCE (FAX)
RELIANCE (ASRM. LLC)
SBMA
SGIC (MULTIPLAN)
SMART MEC PLAN
SOUTH CENTRAL UFCW
SOUTHERN OPERATORS HEALTH
SOUTHWEST SERVICE LIFE
STANDARD SECURITY LIFE (FAX)
STATE FARM MUTUAL
STUDENT RESOURCES (UHC)
SUPERIOR HEALTH CHIP
SUPERIOR HEALTH MEDICAID
SUPERIOR HEALTHPLAN MMP
SYMETRA SELECT
TEAMCARE
TEXAS CHILDREN`S CHIP PERINATE
TEXAS CHILDREN`S HEALTH PLAN
TEXAS CHILDREN`S HEALTH PLAN CHIP
THE AMERICAN WORKER
THE LOOMIS COMPANY
TITLE V
TITLE V PRENATAL
TMHP (TX MCAID & HCARE PTR)
TMHP - FOR NEWBORNS
TML MULTISTATE
TRANSAMERICA
TRICARE
TRICARE SOUTH
TRICARE WEST
TRIWEST (VA)
TRUSTMARK HEALTH BENEFITS
UHC CHIP PERINATE
UHC MEDICARE MMP
UMR
UNICARE MEDICARE SUPPLEMENT
UNIFIED HEALTH SERVICES (PAPER CLA
UNITED BEHAVIORAL HEALTH
UNITED HEALTH CARE
UNITED HEALTH CARE CHIP
UNITED HEALTH CARE MEDICARE
UNITED HEALTH SHARED SERVICES
UNITED HEALTHCARE MEDICAID
UNITED WAY BH PROGRAM
UNITEDHEALTHONE
UPMC HEALTH PLAN
UPPER PENINSULA HEALTH MEDICARE
US FAMILY HEALTH PLAN
USC/BMA
VALUE OPTION
VANTAGE HEALTH PLAN (MEDICARE)
VOCA
WEB-TPA (MULTIPLAN NETWORK)
WELLCARE (TEXANPLUS HMO) *
WELLFLEET
WELLMED
WELLNET HEALTHCARE
WELLNET HEALTHCARE
WESTERN UNITED LIFE
Effective Date
Subscriber Type
--select--
Self
Spouse
Child
Other
Subscriber First Name
Middle
Last/Family Name
Group Number
Policy Number
CoPay Amount
Insurance Address
Attention/Contact
City
State
--select--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code
Contact Phone
Employment Status
--select--
Full-Time Employed
Part-Time Employed
Unemployed
Public Assistance
Retired
Student
Occupation
Employer Name
Employer Address
Employer City
Employer State
--select--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code
Employer County
--select--
Anderson
Andrews
Angelina
Aransas
Archer
Armstrong
Atascosa
Austin
Bailey
Bandera
Bastrop
Baylor
Bee
Bell
Bexar
Blanco
Borden
Bosque
Bowie
Brazoria
Brazos
Brewster
Briscoe
Brooks
Brown
Burleson
Burnet
Caldwell
Calhoun
Callahan
Cameron
Camp
Carson
Cass
Castro
Chambers
Cherokee
Childress
Clay
Cochran
Coke
Coleman
Collin
Collingsworth
Colorado
Comal
Comanche
Concho
Cooke
Coryell
Cottle
Crane
Crockett
Crosby
Culberson
Dallam
Dallas
Dawson
Deaf Smith
Delta
Denton
DeWitt
Dickens
Dimmit
Donley
Duval
Eastland
Ector
Edwards
Ellis
El Paso
Erath
Falls
Fannin
Fayette
Fisher
Floyd
Foard
Fort Bend
Franklin
Freestone
Frio
Gaines
Galveston
Garza
Gillespie
Glasscock
Goliad
Gonzales
Gray
Grayson
Gregg
Grimes
Guadalupe
Hale
Hall
Hamilton
Hansford
Hardeman
Hardin
Harris
Harrison
Hartley
Haskell
Hays
Hemphill
Henderson
Hidalgo
Hill
Hockley
Hood
Hopkins
Houston
Howard
Hudspeth
Hunt
Hutchinson
Irion
Jack
Jackson
Jasper
Jeff Davis
Jefferson
Jim Hogg
Jim Wells
Johnson
Jones
Karnes
Kaufman
Kendall
Kenedy
Kent
Kerr
Kimble
King
Kinney
Kleberg
Knox
Lamar
Lamb
Lampasas
LaSalle
Lavaca
Lee
Leon
Liberty
Limestone
Lipscomb
Live Oak
Llano
Loving
Lubbock
Lynn
Madison
Marion
Martin
Mason
Matagorda
Maverick
McCulloch
McLennan
McMullen
Medina
Menard
Midland
Milam
Mills
Mitchell
Montague
Montgomery
Moore
Morris
Motley
Nacogdoches
Navarro
Newton
Nolan
Nueces
Ochiltree
Oldham
Orange
Palo Pinto
Panola
Parker
Parmer
Pecos
Polk
Potter
Presidio
Rains
Randall
Reagan
Real
Red River
Reeves
Refugio
Roberts
Robertson
Rockwall
Runnels
Rusk
Sabine
San Augustine
San Jacinto
San Patricio
San Saba
Schleicher
Scurry
Shackelford
Shelby
Sherman
Smith
Somervell
Starr
Stephens
Sterling
Stonewall
Sutton
Swisher
Tarrant
Taylor
Terrell
Terry
Throckmorton
Titus
Tom Green
Travis
Trinity
Tyler
Upshur
Upton
Uvalde
Val Verde
Van Zandt
Victoria
Walker
Waller
Ward
Washington
Webb
Wharton
Wheeler
Wichita
Wilbarger
Willacy
Williamson
Wilson
Winkler
Wise
Wood
Yoakum
Young
Zapata
Zavala
Not Listed
Financial Information
Family Size
(including patient)
Total Monthly Income
--select--
$0 to $500
$501 to $1,000
$1,001 to $1,500
$1,501 to $2,500
$2,501 to $3,500
$3,501 to $5,000
$5,001 to $7,500
$7,501 or more
Decline to specify
Special Situations
Homeless Status
--select--
Transitional
Doubling Up
Street
Shelter
Other
N/A
Public Housing
--select--
Yes
No
Migrant/Seasonal
--select--
Migratory
Seasonal
N/A
Veteran Status
--select--
Yes
No
Decline
Patient full name below to digitally sign this form:
Date Signed
Guardian Full Name
Relaionship to Patient
--select--
Self
Spouse
Mother
Father
Sibling
Guardian
Custodian
Grand Parent
Step Parent
Foster Parent
Other Family
Other Non-Family
I acknowledge that I am the parent or legal guardian of this patient and can make decisions concerning health care services for this individual.
Submit Request