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 B1: Indigent Health Care Clinic/Local Health Department Agreement
- Form B2: Point of Entry Agreement
- Form C: Charitable Health Care Provider Annual Reporting Form
- Form D: Indigent Health Care Clinic/Local Health Department Annual Reporting Form