Patient Forms, Policies & Notices

Patient Forms, Policies & Notices

 

Read this first.

pdf-iconKCHC Introductory Letter to Patients

 

This document has everything you need to start with our medical care services.  For dental services, additional information may be needed.

pdf-iconKCHC Welcome All Forms

 

Patient Forms

In order to serve you best, we'll need you to provide us some applicable information.  Save and print out the forms.  Fill them in and get them back to us on or before your visit.

pdf-iconKCHC Dental Clinic Medical History --- This form is only needed for dental patients.

pdf-iconKCHC Financial Acknowledgement 

pdf-iconKCHC Patient Demographic Form

pdf-iconKCHC Release of Information

 

Patient Policies & Notices

Please read through these policies and notices so that you become familiar with what we expect and what you can expect from us.

pdf-iconKCHC Appointment Policies

pdf-iconKCHC HIPAA Privacy Practices

pdf-iconKCHC Policy Change Notice

 

 

health center data silver award

Quality Logo KCHC

KENOSHA COMMUNITY HEALTH CENTER, INC is a Deemed facility by The Health Resources and Services Administration (HRSA), in accordance with the Federally Supported Health Centers Assistance Act (FSHCAA), as amended, sections 224(g)-(n) of the Public Health Service (PHS) Act, U.S.C. §§ 233(g)-(n). As such, KCHC is an employee of the PHS, for the purposes of section 224.

Kenosha Community Health Center, Admin Bldg, 625 57th Street, Ste. 700, Kenosha, WI 53140
(262) 656-0044