BCHS - Primary Care - Charitable Health Program - Download Page
 

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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 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