Patient Forms

Controlled Substance Policy

Riggs has implemented a new policy concerning controlled substances.

  • Riggs Controlled Substance Policy - English
  • Riggs Controlled Substance Policy - Spanish
 

Notice of Privacy Practices

This notice describes how and under what circumstances Riggs Community Health Center may use or disseminate your protected health information. This notice is available below or at the Center

  • Notice of Privacy Practices - English
  • Notice of Privacy Practices - Spanish
 

No Show Policy

To review the Center's No Show Policy, please select a language below. If you have questions regarding the No Show Policy, please contact the Center at (765) 742-1567.

  • Riggs Community Health Center No Show Policy - English
  • Riggs Community Health Center No Show Policy - Spanish
 

Authorization for Release of Medical Records

To obtain a copy of your medical records from Riggs Community Health Center, this form will be required.

  • Authorization for Release of Medical Records - English
  • Authorization for Release of Medical Records - Spanish
 

Authorization to Share Protected Health Information

This form authorizes Riggs to discuss your protected health information with a third party (family member, spouse, care-giver).

  • Authorization for Release of Medical Records - English
  • Authorization for Release of Medical Records - Spanish
 

New Dental Patient Information

Riggs CHC is currently accepting new dental patients, though limited space is available each month.

  • New Dental Patient Checklist - English
  • New Dental Patient Checklist - Spanish
 

Sliding Fee Scale

Center patients without insurance are asked to pay a reduced fee based on their income and a sliding fee scale. A Patient Services Representative will be more than happy to go over the most recent sliding fee scale with you at the Center.

 

Medicaid Enrollment

Apply Online or complete one of the forms below and submit to the health center or directly to Medicaid.

 

Health Insurance Marketplace

 

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