• PAY ONLINE

    PAYMENTS MADE THROUGH THIS SITE ARE ONLY FOR BALANCES AND VISITS PRIOR TO NOVEMBER 2020.

    PLEASE VISIT COPC TO MAKE PAYMENTS FOR ANYTHING AFTER NOVEMBER 2020

Forms

COPC PATIENT FORMS

Patient Packet:

Pediatric Demographic Registration Form

Adult Demographic Form for 18 and Over

Agreement of Financial Responsibility Form

Other Patient Forms:

HIPAA Notice of Privacy Practices

Medical Records Transfer Request

Appointment of Personal Representative

 

        NCH HIE – Overview for Patient Families

        NCH HIE – Registration FAQs

        NCH HIE authorization form

 

 

 

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