Charitable Health - Download Page

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: Charitable Health Care Provider Agreement
• Form B: Indigent Health Care Clinic/Local Health Department Agreement
• Form C: Charitable Health Care Provider Annual Reporting Form
• Form D: Indigent Health Care Clinic/Local Health Department Annual Reporting Form