Clinic Name (from CCHF Dataset)
Start typing the name of your clinic and if your clinic is already known by CCHF you will see it on the list. When you select your Clinic Name, the address fields will be prefilled.
Clinic Name - New
If you don't find your clinic above
Clinic Authorized Primary Contact
Please fill out the contact details of the person who will be updating your clinic information. NOTE: We require your birthdate and the last 4 digits of your Social Security number to verify your identity and keep your clinic information safe.
Last 4 Digits of Soc Sec Number
Executive Director/CEO First Name
Executive Director/CEO Last Name
Executive Director/CEO Email
Executive Director/CEO Job Title
No Med director
We do not have a medical director.
About Your Clinic
What is your clinic's mission statement?
Which type of model best describes your clinic?
Free or Charitable
Federally Qualified Health Center (FQHC)
Does your clinic allow providers and/or staff to provide spiritual care to patients, including, with permission and when appropriate, prayer or encouragement from the Scriptures?
How many hours a week does your clinic see patients?
Please write a short paragraph describing your clinic and services as you would like for it to appear in our online directory.
What year did your clinic start seeing primary care patients?
What types of services does your clinic provide? (Select all that apply)
Traditional Primary Care
Population Specialty Care (HIV, Diabetes, Breast Health, etc.)
Spiritual Health Programs
M.A.T. (Medically Assisted Treatment for Opioid Addiction)
Which best describes your clinic site?
One fixed site
Multiple fixed sites
We have both fixed sites and mobile.
If your clinic has multiple fixed sites, how many?
Which best describes your service environment?
How would you describe your clinic's on-site pharmaceutical services? (If your clinic operates multiple sites, more than one answer may apply.
No Pharmaceutical Services
Are your clinic facilities located in a federally recognized MUA (medically underserved area) or HPSA (health professional shortage area):
Is your clinic a National Health Services Corps site?
How many unduplicated patients did your clinic serve last year?
What percentage of your patients earn less than 200% of the federal poverty level?
What Percentage of Your Patients Are (best guess):
You Clinic's Staff
How many FTE (full-time equivalent) providers does your clinic employ?
Does your clinic provide clinical training/supervision to students? (Check all that apply.)
Do not train students
Medical students & residents
Social work students
Does your clinic offer preceptorship opportunities?
Student Program Coordinator
Student Program Coordinator Email
Secondary Contact: First Name
Secondary Contact: Last Name
Secondary Contact: Email
Secondary Contact: Phone
CLINICAL AND PRE-CLINICAL TRAINING
SUMMER PRE-CLINICAL EXPERIENCES
Hours/Week Offered for Clinical Training
Length of Rotations
Disciplines Eligible for Rotation
PRIMARY CARE RESIDENTS
Housing can accommodate families?
General Description of the Program
Goals and Objectives
Core or elective rotation site?
Your Signature and Payment
Clinic membership annual dues are based on a sliding scale relative to your organization's annual budgeted revenue. Suggested donation amounts are:
+$100 for every million above $3M
My clinic has already paid the annual dues
Please bill my clinic
Please Bill My Clinic
Pay now! Membership Amount
First Name on Card
Last Name on Card
Please sign your application by typing your full name.
Signature of Authorized Clinic Representative