Patient Forms

Patient Forms

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Our Patient Forms

Please complete these forms in order to register for care with us:

Patient Registration (English)
Download Form
Patient Registration (Español)
Download Form
Terms of Service (English/Español)
Download Form
Patient Attendance Policy
Download Form
Patient Information Form (English)
Download Form
Patient Information Form  (Español)
Download Form
Information Release (English)
Download Form
Information Release (Español)
Download Form
Behavioral Health Department Referral Form
Download Form

Frequently Asked Questions

We are part of your community and are ready to help you! See below some of the frequently asked questions we get. If you can not find the answer to you question here, please call us at 203-503-3000.

  • Who can visit us?

    Anyone and everyone. No matter who you are, you can seek help for your healthcare needs with us.

  • How do I make an appointment?

    Call the main number 203-503-3000 or visit one of our locations.

  • Is Cornell Scott-Hill Health Center a free clinic?

    No, we are not a free clinic. We provide healthcare services for a fee. However, because we are a Federally Qualified Health Center, we are able to offer reduced rates to people without insurance as long as they qualify based on income and family size.

  • How much do your services cost?

    Costs will vary based on your specific situation. We accept all insurance including Medicare, Medicaid (Title 19), HUSKY, Charter Oak, and most commercial insurance plans. For anyone without health insurance, we offer services on a sliding-fee scale, which means you pay only what you can. We also can provide assistance with access to State support and services.

  • How can I give feedback about my experience here?

    You may fill out a comment card located in the reception area or right on this website each service can be rated.

  • How can I obtain my medical records?

    Release of information requests are processed by Ramona Fain and Francheska Cantey. Francheska handles all patients that falls between A-M and Ramona N-Z. Ramona can be reached at 203-503-3140 and Francheska at 203-503-3236.

  • How can I know if the center is delayed or closed due to severe weather?

    Our 24/7 facility SCRC will remain open during severe weather. To find out if there are delays or closings at any of our other sites go to:


    Channel 3: WFSB Early Warning Network - www.wfsb.com


    Visit our site at: www.cornellscott.org