Clinic Patient Forms

Commonly Used Patient Forms

HIPAA Authorization (pdf)

This is needed for first time patients, patients who have not been to the clinic since the EHR implementation, or whose information may have changed.

 HIPAA Notice of Privacy Practices (pdf)

This Notice describes how medical information about you may be used or disclosed and how you can get access to this information. Please review it carefully.

Migrant Farm Worker Services Form (pdf)

This form is for patients that qualify as a farm worker and helps to define your status as either a migrant farmworker, seasonal farmworker, or wife, husband, child or parent of a person working in agriculture.

Nuevo paquete paciente (pdf)(español)

This is needed for first time patients, patients who have not been to the clinic since the EHR implementation, or whose information may have changed.

Patient Registration Form (pdf)

This is needed for first time patients, patients who have not been to the clinic since the EHR implementation, or whose information may have changed. This form can be filled out easily in Microsoft Word.

Patient Rights & Responsibilities (pdf)

This document discusses patient rights and responsibilities related to human rights, payment services, privacy, health care, chc rules, complaints, and termination of care.

Sliding Fee Application and Scale - Community Health Centers (pdf)

Sliding Fee Application and Scale (Spanish) - Community Health Centers (pdf)

This document contains the sliding fee scale and sliding fee application for the Community Health Centers. If necessary income information for the Sliding Fee discount requires verification from Employers, Department of Social Services, Tennessee Employment Commission, Social Security Office, and to provide other Health Center and/or Hospitals financial and medical information when needed, please complete the Release of Information For Sliding Fee Discount Evaluation below.

Sliding Fee Application and Scale - Mountain City Extended Hours Clinic Only (pdf)

This document contains the sliding fee scale and sliding fee application for the Mountain City Extended Hours Health Clinic. If necessary income information for the Sliding Fee discount requires verification from Employers, Department of Social Services, Tennessee Employment Commission, Social Security Office, and to provide other Health Center and/or Hospitals financial and medical information when needed, please complete the Release of Information For Sliding Fee Discount Evaluation below.

Release of Information For Sliding Fee Discount Evaluation (pdf)

This must be completed before we can fax or mail any information to the patient or third party, at the request of the patient. Costs apply depending on the number of pages you are requesting, please call for an exact price 423-439-4225. Prepayment is required!  Please allow 2 weeks for processing, and any information will only be sent to ONE address.

Vaccine Consent Form Hancock County Schools (pdf)

This form is to be used to request the administration of required immunizations at a Hancock County School Based Health Center  for a child attending Hancock County Schools.