Enrollment Form

CHCL Enrollment Form - English V2

Please take 45 minutes to fill out the CHCL Digital Registration Process.

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CONFIDENTIAL ENROLLMENT FORM

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.

PATIENT INFORMATION

Sexual Orientation *
Gender Identity *

GURANTOR/GUARDIAN

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.

Self

HOUSEHOLD FAMILY MEMBERS

$

Click HERE to Add Additional Household Members (Up To 4)

Add additional household members below, if there are no additional household members, leave the fields blank.

Click HERE to Add Additional Household Members (Up To 4)

Add additional household members below, if there are no additional household members, leave the fields blank.

Click HERE to Add Additional Household Members (Up To 4)

Add additional household members below, if there are no additional household members, leave the fields blank.

Click HERE to Add Additional Household Members (Up To 4)

Add additional household members below, if there are no additional household members, leave the fields blank.
All household income combined.

Proof Of Income

If you have paychecks available, upload them by taking a picture of a physical check or a screenshot of your payment portal.
Upload Check
Maximum upload size: 7MB
Upload Check
Maximum upload size: 7MB

INSURANCE INFORMATION

Do you have insurance? *
Select Your Insurance Type
Upload Insurance Card (FRONT)
Maximum upload size: 5MB
Upload Insurance Card (BACK)
Maximum upload size: 5MB

Policy Holder Information (If Not Patient)

Are you the policy holder?

ADDITIONAL PATIENT DATA

Check all that apply:
Martial Status *
Patient Employment *
Preferred Language *
Migrant *
Veteran *
Housing Status *
Race *
Ethnicity *

EMERGENCY CONTACT

By signing this form you agree your electronic signature is the legal equivalent of your manual signature on this Agreement.

Need a Doctor for a Check-Up?

Just make an appointment and we will take care of the rest.

The Community Health Center of Lubbock

Contact Information

CHCL Main Clinic
Address: 1610 5th Street, Lubbock, Texas 79401
Phone: 806-765-2611
Fax: 806-765-2637
E-mail: info@chcl.tachc.org
Notice of Deemed Status:
This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals. For more information, see http://www.bphc.hrsa.gov/ftca/.