Patient Information and Forms
Thank you for your interest in Community Health Center of Fort Dodge with locations in Fort Dodge, Mason City and Dayton Iowa. We are proud to serve as your medical home and commit to a quality experience for your health care needs.
Advanced appointments at Community Health Center of Fort Dodge, Mason City and Dayton are preferred. However, for urgent needs, efforts will be made for you to see a provider the day you call.
Please give us a call if you are unable to make your scheduled appointment. Children under age 18 need to be accompanied by a parent. Please review our no show policy here.
What to Bring On Your First Visit
For your first visit at, you will be asked to complete new patient forms. These forms become part of your medical chart and include demographic information such as your address, phone number, employment and insurance carriers. Other new patient forms will include a basic questionnaire of your personal and family health history. To qualify for our sliding fee programs, uninsured or privately insured patients are also asked to bring proof of their household income. A financial counselor will assist with this process.
Please be prepared to provide the following information:
- Date of Birth
- Phone Number
- Description of Medical or Dental Problem
- Title 19
- Most Private Insurance
- Affordable Care Act Health Plans
- Discount Fee Schedule (for those who qualify)
- Please bring income verification
We accept cash, check, and most major credit cards.
Sliding Fee Discount Program
Patients without insurance may be eligible for a discount based on household size and income. You must apply for the discount.
- Please bring proof of household income to your appointment at CHCFD to see if you are eligible for the sliding fee discount.
- Sliding fee scales need to be reapplied for on a yearly basis, or if a household size/income changes.
If you do qualify for the sliding fee program, you will be asked to pay a nominal fee. This will be applied to the charges for your visit at Community Health Center of Fort Dodge, Mason City or Dayton.
The following is the information you should bring with you when you come to your first appointment to see if you qualify for the sliding fee discount:
- Proof of household annual income, such as copies of…
- Pay stubs (last 30 days)
- Income tax form (current year)
- Food stamps
- Award letters (SSI, SSDI)
- Dividend/interest statement
- Statement from individual providing support
- Current benefit check (copy)
Laboratory Service Fees
All uninsured patients have the option to utilize our outsourced lab at a discounted rate, which must be paid at the time of service. Fees for labs are dependent on the type of labs ordered by the provider and will be disclosed at the time of the service. Please ask your CHCFD Health Care Staff for clarification.
Please print the necessary forms and bring the completed forms with you to your appointment, as well as a copy of your insurance card and photo ID. If you are unable to print the forms below we will provide you with the necessary forms when you arrive for your appointment.