Charitable Health - BLRH Download Page

BLRH Download Page

Charitable Health Provider Forms

Below are copies of the forms used by the Charitable Health Provider Program.

(To download these files, right-click and choose "Save As")

• Form A Point of Entry Registration Form
• Form B Indigent Health Care Clinic Agreement
• Form C Patient Eligibility Certification (English)
• Form C Patient Eligibility Certification (Spanish)
• Form E Report Form
• Form F Agreement to Provide Charitable Services

Click here to contact the BLRH staff member responsible for this program.