Download Forms

Online Forms

Please print and fill out the following forms to bring along on your first office visit. Also, remember to bring a picture ID, proof of income, and insurance card(s).

Trinity Community Health Centers of Louisiana Documents

• Notice of Privacy Practices

• Contact Information

• Notice of Acknowledgement of Advance Directives

• Patient's Bill of Rights and Responsibilities

• Release of Information:

Print and complete the following:

• Name

• Address 

• Date of Birth

• Social  Security #

• Facility or Doctor Information for Request for Records

• Sign and Date

Once complete return the form to your local health center. 

• • • Avoyelles Community Health Center 

    • Bienville Community Health Center

    • East Grant Community Health Center

    • Grant Community Health Center

    • Lincoln Community Health Center

    • Rapides Community Health Center

    • Winn Community Health Center

Trinity Community Health Centers of Louisiana Forms

• New Patient Information Form

To make an appointment, please contact the location of your choice. 

Trinity Community Health Centers of Louisiana Dental Forms

Locations: Bienville - Grant - Lincoln - Winn

• Dental Patient History Form

To make an appointment, please contact any of the locations listed above.

 Behavioral Health Forms

• NICHQ Vanderbilt Assessment Scale – PARENT Informant Form

• NICHQ Vanderbilt Assessment Follow-up – PARENT Informant Form

 Patient Notices

• 2023 Medicare Beneficiary Notice