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".