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Contact Info x

  • Community Health Center of the North Country | Canton
  • Phone: (315) 386-8191
  • Fax: (315) 386-1410
  • Community Health Center of North Country | Malone
  • Phone: (518) 483-0109
  • Fax: (518) 483-0115
  • Community Health Center of North Country | Watertown
  • Phone: (315) 786-0983
  • Fax: (315) 786-0994
  • Community Health Center of the North Country | Gouverneur
  • Phone: (315) 287-4440
  • Fax: (315) 287-1858
  • Community Health Center of the North Country | Ogdensburg
  • Phone: (315) 713-9350
  • Fax: (315) 713-9351

ADULT NEW PATIENT PACKET

Welcome to Our Practice

Services Available by Location 

Sliding Fee Scale

HIPAA Notice of Privacy

FQHC Survey *

Health History Form *

Consent to Discuss PHI *

Consent for Treatment *

HIXNY Consent Form *

HealthEConnections Consent Form * 

Psychosocial Needs Assessment *

Telehealth Consent Form *

Forms marked with a * are required to be filled out prior to your visit.

Bienvenida a nuestra practica

Servicios disponibles por ubicación

Escala de tarifas

Aviso de privacidad de HIPAA

Encuesta FQHC *

Formulario de historial de salud *

Consentimiento para discutir PHI *

Consentimiento para el tratamiento *

Formulario de consentimiento de HIXNY *

Formulario de consentimiento de HealthEConnections *

Evaluación de necesidades psicosociales *

Formulario de consentimiento de telesalud *

Los formularios marcados con un * deben completarse antes de su visita.

  • Copyright © 2023 Community Health Center of the North Country | Canton, all rights reserved.
  • 4 Commerce Lane,  Canton, NY 13617   (315) 386-8191