Patient Forms (West Side)

Hawaiʻi Island Community Health Center provides you with the opportunity to complete or view our patient forms before your appointment. PDF forms are provided below.

Hawaiʻi Island Community Health Center is committed to protecting the privacy of our patients and complies with the Health Insurance Portability and Accountability Act (HIPAA). We encourage our patients to read their Patient Rights and Responsibilities to be well-informed and discuss their decisions with our health care team.

Medical

English

• Adult New Patient Packet
• Adult Medical Health History
• Keiki (Pediatric) New Patient Packet
• Keiki (Pediatric) Medical Health History
• Authorization for Release of Information
• Medicare Annual Wellness Visit Questionnaire

Spanish

• Adult New Patient Packet
• Keiki (Pediatric) New Patient Packet

Marshallese

• Adult New Patient Packet
• Keiki (Pediatric) New Patient Packet

Dental

• Adult Dental New Patient Packet
• Keiki (Pediatric) Dental New Patient Packet

Forms for Help with Payment

• Sliding Fee Scale Discount Application

Three easy ways to submit your forms:

1. Fax: Scan completed forms and fax to 808-329-9451 or 808-329-5057
2. Email: Scan completed forms and email them to medical.records@hicommunityhealthcenter.org
3. In-Person: Bring your completed forms to our Kuakini Health Center, where you can drop them off with one of our medical screeners without even coming inside. 75-5751 Kuakini Highway, Ste. 104, Kailua-Kona, HI 96740