Enrollment Form - The Community Health Center of Lubbock

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Online Enrollment Form

CHCL Enrollment Form - English V2

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

Patient Information
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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

Patient Name: *

Date of Birth: *

Social Security Number *

Mailing Address *

City *

State *

Zip Code *

Cell Phone Number

Home Phone Number

Work Phone Number

Email *

Sexual Orientation *

Heterosexual

Lesbian/Gay

Bisexual

Gender Identity *

Male

Female

Transgender M to F

Transgender F to M

OtherOther

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

Yes

First Name *

Middle Name

Last Name *

Suffix Suffix

Date of Birth *

Social Security Number *

Relationship *

HOUSEHOLD FAMILY MEMBERS

How much income do you make? *

How often? * How often?

From where is your income? From where is your income?

Add Additional Household Members (Up To 4)

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

Full Name

Relationship Relationship

Date of Birth

Social Security Number

Income

How Often? How Often?

From where? From where?

Add Additional Household Members (Up To 4)

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

Full Name

Relationship Relationship

Date of Birth

Social Security Number

Income

How Often? How Often?

From where? From where?

Add Additional Household Members (Up To 4)

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

Full Name

Relationship Relationship

Date of Birth

Social Security Number

Income

How Often? How Often?

From where? From where?

Add Additional Household Members (Up To 4)

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

Full Name

Relationship Relationship

Date of Birth

Social Security Number

Income

How Often? How Often?

From where? From where?

Yearly Household GROSS Income (Combined) *

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? *

Yes

Select Your Insurance Type

Private Insurance

Medicare

Medicaid

CHIP

Healthy Texas Women

Blue Card

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?

Yes

Full Name

Relationship Relationship

Date of Birth

Social Security Number

ADDITIONAL PATIENT DATA

Check all that apply:

Martial Status *

Single

Married

Divorced

Widowed

Seperated

Patient Employment *

Full Time

Part Time

Student

Disabled

None

Preferred Language *

English

Spanish

OtherOther

Migrant *

None

Migrant

Seasonal

Veteran *

Yes

Housing Status *

Buy

Rent

Public Housing

With Others

Shelter

Street

Race *

White

Black

Asian

OtherOther

Ethnicity *

Not HIspanic

Hispanic/Latino

EMERGENCY CONTACT

Full Name *

Relationship * Relationship

Phone Number *

Signature *

Clear

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

Date

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Locations

CHCL Main CLinic
96 West
Arnett Benson Medical and Dental
Chatman Clinic
Community Dental Clinic
Medical Office Plaza
Parkway Clinic
West Medical and Dental Clinic

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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/.