CSH Online Form

Please fill out this form and click SEND EMAIL. To learn more about the plan, please read All About the CSH. This plan is an option, not a requirement. We also have a printable form if you would like to bring it in or fax it to us. If you are a new patient, please also fill out the New Patient Form.
Would you like to add a few more dollars to your monthly contribution to help seriously ill patients? If so, please go here to donate to the Medicine Support Fund.





($50 per adult is suggested, $25-$100 sliding scale--please pay at your maximum to keep the plan supported. We will begin billing this amount the 1st of the next month, and the plan will carry you 6 months from the 1st.)

Terms:  Due to the number of declined cards and unpaid invoices with the CSH, we now require 2 debit or credit cards for sign-up in order to continue to provide this as a low rate option. We can accept the full amount for 6 months in advance as well. Your card will be charged the 1st of each month, and your back-up card will be charged if your primary card fails. The plan will automatically renew after 6 months. Please call us prior to your expiration if you need to cancel, since we cannot do refunds if you forget (we also do not do retroactive billing for late sign-up). If you need to cancel mid-way, there is a $150 cancellation fee. After canceling your plan at any time, the cost is $150 to rejoin. Please note that our regular 24-hour cancellation policy for appointments still applies. We can provide insurance forms only after an appointment for the amount paid that month. We do allow adjustments in your rate if your income fluctuates. Thanks for your cooperation!


Need more information before agreeing to these terms? Click here

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