Local Health Department Forms

CDP Portal - Forms Ordering

• Pamphlet Library Publication Request Form (CHFS-1210):
  • Instructions
  • Request Form

Security Request Forms:

• L Drive Security Access Request Form 
• Local Health Network Security Request (Rev. 5/15/13)
• CMS Portal Security Request Form (Rev. 5/15/13)
• EHMIS Security Request Form
• CDP - Oracle Discoverer - User Authorization Request
• CDP - Report Server - User Authorization Request

CDP Extra Hours Request:

• CDP Extra Hours Procedures
• CDP Extra Hours Request Form

Other LHD Forms:

• CH-45 Patient Encounter Form (Rev. 3/8/13)
  • Word format
  • PDF format
  • CH-45 Instructions
• Admin. Codes with Vaccine Info. (1/25/11)
• CH-47 Patient Services Supplemental Reporting Form (Rev. 10/1/12)
  • Word format
  • PDF format
• CH-48 Community Health Services Report (Rev. 7/1/10)
• CH-5 Forms:
  • CH-5 (Rev. 3/13)
  • CH-5 (Rev. 3/13) Spanish
  • CH-5B (Rev. 1/1/11)
    • CH-5B Instructions
  • • Attachments to be included if CH-5B mailed or when applicable:
      • Instructions for Completing CH-5B (Patient/Client)
      • Household Income Definition
      • WIC Participant Rights and Responsibilities
  • CH-5B (1/1/11) Spanish