Centerstone Health Services
  • Home
  • Who We Are
  • Bloomington Clinic
  • Connersville Clinic
  • New Patient Info
  • MyMedicalLocker
  • Search
  • Menu Menu

BLOOMINGTON

New Patient Forms

Get Started!

1

READ THE INSTRUCTIONS BELOW

2

FILL OUT THE REQUIRED FORMS

3

CALL YOUR CLINIC TO SCHEDULE AN APPOINTMENT

Form Instructions:

Please fill out the forms below. Note that all of the forms are required except the Sliding Fee Scale. We encourage you to find out if you’re eligible to take advantage of this cost-saving program by visiting our Sliding Fee Scale info page or calling the clinic at 812-269-5092.

Policies:

As you work your way through the forms below, you’ll be asked to acknowledge receipt of our HIPAA Privacy Practices Notice and our Attendance Policy. You can review and download these policies by downloading our Policy Packet.

Clicking each of the links below will open a form in a new browser window. To return to this page, simply close the browser tab and select the next form in the list.

  1. Attendance Policy Acknowledgement*
  2. HIPAA Acknowledgement*
  3. Emergency Contact Information*
  4. Patient Registration Form*
  5. Patient Health Questionnaire*
  6. Release Authorization*
  7. Sliding Fee Screening

*= required

Downloads:

CHS Policy Packet

Visit the link above to read and download our policy packet.

  • Who We Are
  • Sliding Fee Scale
  • New Patient Info
  • Privacy
  • Terms
  • COVID 19 Policy

Locations

News

Centerstone Health Services Bloomington

645 S Rogers St
Suite A
Bloomington, IN 47403
(812) 269-5092
Fax:(812) 269-5095

Centerstone Health Services Connersville

390 Erie Ave
Suite A
Connersville, IN 47331
(765) 377-1205
Fax: (765) 377-1209

Subscribe to Our eNews

© 2021 Centerstone Health Services | Powered by Nerdsy

Scroll to top
PLEASE READ OUR COVID 19 NOTICE. IF YOU HAVE SYMPTOMS, PLEASE CALL US PRIOR TO YOUR APPOINTMENT!
COVID-19 NOTICE