Crossroad Health Center
5 E. Liberty Street,
Cincinnati,
OH 45202
(513) 381-2247
Crossroad Health Center West
2859 Boudinot Avenue Suite 107,
Cincinnati,
OH 45238
(513) 922-4271
Patient Forms
For your convenience, below are the forms that you will be asked to complete when you arrive for your appointment. Please click on the form to print and bring with you to your appointment.
For all patients, we ask for your assistance in providing us with information regarding your household income. Please complete the “Grant Data Collection” form. 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.
If you have no insurance, 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". If you have no income or are unable to provide proof of your income, please complete the "No Income Verification" form.
New Patient Form
(New Patient Form.pdf)Consent to Treat
(Consent-to-Treat.pdf; 63KB) Notice of Privacy
(Notice-of-Privacy.pdf; 99KB) Grant Data Collection
(Grant-Data-Collection.pdf; 111KB)Sliding Fee Discount Application
(Sliding-Fee-Discount-Application.pdf; 67KB)No Income Verification
(No-Income-Verification.pdf; 5KB)
