Forms & Brochures | Eagle View Community Health

Your Home for Healthcare

Locations in:

Stronghurst, IL

MONMOUTH, IL COMING FEBRUARY 2023

Call Us! Toll Free
1-866-346-1337

Se habla español

Please be advised that this toll free number directly connects to our Stronghurst office

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gove/nosurprises or call 1-800-985-3059

Doctor Checking a Form

BROCHURES & FORMS

Affordable Care Insurance Brochure

Sliding Fee Scale
Information

Online Pediatric Health History Form

Printable Adult Health History Form (English)

Authorization to Disclose Protected Health Information

Sliding Fee Application
(English)

Online Eagle View Patient Registration Form

Printable Pediatric Health History Form (English)

Notice of Privacy Policy

Online Adult New Patient Packet

Online School-Based Health Center Student Registration Form

Online DOT Form

Spanish Forms

Información Sobre el Mercado de Seguros Medico (Affordable Care Act)

Notice of Privacy Policy

Conozca Sus Derechos en el Mercado de Seguros Medico (Spanish)

Sliding Fee Scale
Information

Escala Móvil de Tarifas
Aplicación (Spanish)

Formulario de Historial Dental para Adultos (Spanish)

Formulario de Historial Dental para Niños

(Spanish)

Formulario de Historial Médico (Spanish)