Home » Enrollment Form
Please take 45 minutes to fill out the CHCL Digital Registration Process.
Please have your check stubs, social security, insurance card, and immunization cards ready. Failure to disclose insurance and financial information or declination of assistance would mean paying 100% of your bill at CHCL.
If this enrollment is for you, select Yes under Self below.
If you are a guarantor, parent or guardian filling out the enrollment form on behalf of the patient, please fill enter your information below.
Policy Holder Information (If Not Patient)