New Patient Forms & Information
Welcome!
Community Health & Wellness is committed to providing quality compassionate healthcare. Our professional caring staff is committed to working with you to achieve your health care goals. Please call 860-489-0931 to inquire if we are in network with your insurance carrier. Patients with limited English proficiency will be offered translation services free of charge.
New Patient Forms
If you are a new patient who has an appointment at the center, you can click on new patient forms below and print the registration form.
Please complete this form in its entirety and bring it to your appointment along with your driver’s license and insurance card if you have one.
New Patient Registration Form
New Patient Registration Form Spanish
Financial Aid Forms
If you are without health insurance coverage and have an appointment at the center, there is financial assistance for those who qualify. You may click below and print out the financial assistance application. Please complete the application in its entirety and bring it along with any required documentation to your appointment. Our financial counselors will process your paperwork to see if you qualify for a sliding fee. All copays and payments are due at time of service.
Application for Financial Aid – English (PDF)
Application for Financial Aid – Spanish (PDF)
No Show Policy
There is a very high volume of individuals waiting for appointments at our center. Appointments are in great demand. Community Health & Wellness has established a No Show Policy in order to meet our patient demand for appointments. It is the Patient’s Responsibility to notify the office at least 24-48 hours in advance of their scheduled appointment to reschedule or cancel so we may offer the time to another patient waiting to be seen.
When a patient misses two scheduled appointments without notifying the office, the next requested appointment will be stand by. (This means no scheduled appointment time will be given and the patient will have to sit and wait for a provider to have an opening in their schedule) Unfortunately, there is no guarantee you will be seen on that day; you may have to return the next day until a provider has an opening in his/her schedule. By implementing this policy, we believe we honor patients who schedule/keep their appointments while accommodating everyone who needs to be seen more efficiently.
Patient Bill of Rights
Community Health & Wellness is committed to providing quality, compassionate, and professional health care that is affordable, easily accessible, and without discrimination to all residents of the Northwest Corner of Connecticut.
In keeping with the above mission, CHWC places high priority on your involvement in your healthcare. Knowing your rights as a patient is an important part of this involvement.
As a patient at CHWC, you are entitled to the following.
Health Information Exchange (HIE) Disclosure
Community Health & Wellness participates in health information exchange (HIE) to enhance the quality of care provided to our patients.Health information exchange is a free, secure service that makes your health information available to all your doctors regardless of where you’ve received care.
You may opt out of the Health Information Exchange by contacting a Patient Access Representative at (860) 489-0931.
Community Health & Wellness is committed to providing quality compassionate healthcare. Our professional caring staff is committed to working with you to achieve your health care goals. Please call 860-489-0931 to inquire if we are in network with your insurance carrier. Patients with limited English proficiency will be offered translation services free of charge.
New Patient Forms
If you are a new patient who has an appointment at the center, you can click on new patient forms below and print the registration form.
Please complete this form in its entirety and bring it to your appointment along with your driver’s license and insurance card if you have one.
New Patient Registration Form
New Patient Registration Form Spanish
Financial Aid Forms
If you are without health insurance coverage and have an appointment at the center, there is financial assistance for those who qualify. You may click below and print out the financial assistance application. Please complete the application in its entirety and bring it along with any required documentation to your appointment. Our financial counselors will process your paperwork to see if you qualify for a sliding fee. All copays and payments are due at time of service.
Application for Financial Aid – English (PDF)
Application for Financial Aid – Spanish (PDF)
No Show Policy
There is a very high volume of individuals waiting for appointments at our center. Appointments are in great demand. Community Health & Wellness has established a No Show Policy in order to meet our patient demand for appointments. It is the Patient’s Responsibility to notify the office at least 24-48 hours in advance of their scheduled appointment to reschedule or cancel so we may offer the time to another patient waiting to be seen.
When a patient misses two scheduled appointments without notifying the office, the next requested appointment will be stand by. (This means no scheduled appointment time will be given and the patient will have to sit and wait for a provider to have an opening in their schedule) Unfortunately, there is no guarantee you will be seen on that day; you may have to return the next day until a provider has an opening in his/her schedule. By implementing this policy, we believe we honor patients who schedule/keep their appointments while accommodating everyone who needs to be seen more efficiently.
Patient Bill of Rights
Community Health & Wellness is committed to providing quality, compassionate, and professional health care that is affordable, easily accessible, and without discrimination to all residents of the Northwest Corner of Connecticut.
In keeping with the above mission, CHWC places high priority on your involvement in your healthcare. Knowing your rights as a patient is an important part of this involvement.
As a patient at CHWC, you are entitled to the following.
- The right to respectful and considerate care, regardless of your age, race, color, sex, religion, sexual orientation, marital status, national origin, immigration status, or ability to pay for services.
- The right to timely, high quality health care from clinicians who are experienced and trained to meet your medical needs.
- The right to have your personal and medical information and records treated confidentially and to be able to approve or refuse the release of your information to a third party, except as required by law.
- The right to information in your medical record.
- The right to participate in your care, including decisions about procedures, treatment, or research.
- The right to explanation of your diagnosis, treatment, and prognosis in terms you can understand.
- The right to refuse treatment to the extent permitted by law, and to be informed of the medical consequences of your decision.
- The right to know the name, profession, and level of training of your health care provider or any other CHWC employees or volunteers; to change providers if other qualified providers are available, and to request alternative referrals if those made by CHWC are unacceptable to you.
- The right to know how to access care during off-hours.
- The right to receive an itemized copy of your account upon request, to be informed of your eligibility for free care, reduced-cost care, or third party reimbursement.
- The right to information about CHWC, the services we offer, our fees, and our bill paying policies. The right to voice grievances or complaints, and to suggest changes in our policies and procedures. The right to a copy of the CHWC patient grievance procedure through CHWC staff.
- The right to have your complaint investigated by CHWC and timely solution presented to you, in writing if you wish.
- The right to be informed of the rules and regulations at CHWC that apply to your conduct as a patient.
- The right to have your personal privacy respected by all CHWCstaff.
Health Information Exchange (HIE) Disclosure
Community Health & Wellness participates in health information exchange (HIE) to enhance the quality of care provided to our patients.Health information exchange is a free, secure service that makes your health information available to all your doctors regardless of where you’ve received care.
You may opt out of the Health Information Exchange by contacting a Patient Access Representative at (860) 489-0931.
