New Patients

Placeholder Image
Fields in bold are required.

      Gender:  
   Is your insurance coverage through a Community Health Partnership (CHP) employer group plan?  


   Are you related to or applying with another family member?  

   Medical history for the past 10 years
   (This is important for finding a provider who is knowledgeable with treating any conditions you may have.)
   Have you been a previous patient?  
   Current medications
   Please provide an accurate list of medications you are currently taking. Medication omissions may result in denial of application.
   Are you willing to use Community Hospital?  
   Do you use any tobacco products?  

Please do not use this area to contact us regarding your personal medical issues. Please call us with questions about your medications or medical treatment. This information is sent to a referral coordinator for new patient applications only. If you are a current patient, please contact your provider.