South Cove Community Health Center
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Incident Report / Patient Complaint Form

Patient Informed Refusal

Patient Informed Refusal Chinese Version

SC Automated Phone Message

Travel Reimbursement Form

Behavioral Health

Telehealth Consent Form – English

Telehealth Consent Form – Chinese

Closing Reports

Closing Report – Quincy

Closing Report – South St

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HR Forms

Form M-4

Form W-4 and Guide

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Additional HR Plan Enrollment Forms

If you need to apply for Family Medical Leave, please contact Employee Benefits at 617-521-6701.

Medical Record Forms

Request to Disclose Health Information

Request to Disclose Health Information (Chinese)

Request to Obtain Health Information

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Medical Record Release Denial

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Fax Transmittal Form

BH Medical Record Release Denial

Medical Record Notice of Copying Fee

Dental Forms

Dental Department Refund Form

Dental Medical Clearance Form

Excuse for Absence

Schedule Change Form

Non Covered Dental Care Acknowledgement Form

Patient Treatment Refusal Form Eng/Chinese

Patient Payment Agreement

Prenatal Dental Visit Checklist

Young Children Dental Exam Checklist

Boston University Referral Form – Periodontics

Jade Orthodontics

SCCHC Patient Referral (Out Going from SCCHC)

Dental Examination Form

Dental – Medical History

OB/GYN Form

CMFM referral form 10-2017 (Homles)

Order form for BCH MFCC_correct

Order form for BCH MFCC_correctEmployee Data Maintenance

Teen Confidentiality Consent Form

System Access Request Forms

BIDMC Disable System Access Request Form

BMC Chartlink Confidentiality Agreement

Confidentiality Acknowledgement

SCCHC Information System Request Form

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