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.

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
Sliding Fee Discount Program

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".

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.

Welcome to Crossroad

New Patient Form

Medical Record Request

Consent to Treat

Notice of Privacy Practices

Women's Health History

Prenatal Patient Registration

Prenatal Patient Medical History

Pediatric Patient Registration

Pediatric Patient Medical History

Patient Registration-New Patient

Patient Medical History-New Patient

Grant Data Collection Form

Sliding Fee Discount Application