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

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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, 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". 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)
Use or Disclosure of PHI
(Use or Disclosure of PHI.pdf)

Attention All Patients with No Insurance

You might be eligible to receive insurance through the new Health Insurance Marketplace.

 
Learn about the Health Insurance Marketplace & your new coverage options through Obamacare

 

To contact Crossroad's Outreach & Enrollment Specialists, call 513-381-2247 or email insurance@crossrd.org

Click here to download the application form for the Health Insurance Marketplace.