Crossroad Health Center

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        • Community Health Education Program Application
      • For Current Students
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  • About
    • COVID-19 Info
    • History
    • Leadership
    • Providers
    • Hours & Locations >
      • Over-the-Rhine
      • Rothenberg
      • Taft
      • Western Hills
      • Harrison
    • Financial Information
    • Privacy Policy
    • Contact Us
  • Patients
    • New Patients
    • Current Patients
    • Support Groups
    • Paperwork
    • Resources
    • Feedback
  • Get Involved
    • Learn >
      • Care Coordination Team
      • Volunteer Internship Program
      • Community Health Education Program >
        • Community Health Education Program Application
      • For Current Students
  • Donate
  • Careers
    • Application

Paperwork

For your convenience, below are the forms that you will be asked to complete when you arrive for your appointment. You may click the link to print the form, complete it, and bring it with you to your appointment. 

New Patient Form

English | Spanish

Medical Record Request

English

Consent to Treat

English | Spanish

Notice of Privacy Practices

English | Spanish

Grant Data Collection Form

English | Spanish
For all patients, we ask for your assistance in providing us with information regarding your household income. This information helps us tremendously when applying for grant funding. Crossroad relies on grant funding to help offset some of our costs in order to keep our services affordable.

Sliding Fee Discount Application

English | Spanish
If you do not have insurance, we will help you determine if you are eligible for Ohio Medicaid or the Health Insurance Marketplace. If you are not eligible for Ohio Medicaid or the Health Insurance Marketplace, you may be eligible for a sliding fee (discounted fee based on your household income). To determine your eligibility, please complete the "Sliding Fee Discount Application".

About | Contact | Hours & Locations 

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Our mission is to give honor to Jesus Christ by providing accessible, comprehensive health care in partnership with our patients and community leading to healthy, changed lives.
This health center receives HHS funding and has federal Public Health Service deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals." For more information, please see http://www.bphc.hrsa.gov.ftca/
Christian Community Health Services (dba Crossroad Health Center) is a tax-exempt 501(c)3 organization. Copyright © 2020 Crossroad Health Center. All rights reserved. This health center is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).
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