Administrative Office 727-824-8181 1344 22nd St South, St. Petersburg, FL 33712 >Directions   
This health center is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n). In addition, if the health center is asked who your insurance carrier is for purposes of filing medical malpractice claims, you should respond in writing whenever possible -- by stating that they and many/all of their providers are deemed federal employees, with resultant coverage under the Federal Tort Claims Act (FTCA) for actions within the scope of deemed employment, pursuant to 42 U.S.C. 233(g)-(n). Accordingly, claims or notice of medical malpractice claims should be submitted by a claimant to the Office of General Counsel at the address below. Further, the health center should retain a copy of this correspondence in their office files, rather than in patient medical records. U.S. Department of Health and Human Services Office of the General Counsel General Law Division 330 Independence Ave., S.W. Room 4760 Mail Stop: Capitol Place Washington, DC 20201  
Our Mission
Community Health Centers of Pinellas's mission is to provide quality healthcare services to all.
Forms
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Community Health Centers of Pinellas, Inc. •
Adult Forms
Pediatric Forms
GYN Forms
OB Forms
Registration Form Bill of Rights, Privacy, Advanced Directive Consent for Treatment Form Privacy Notice Patient Medical History Insurance Verification Consent for Use and Disclosure of PHI Bill of Rights, Responsibilities and Information
Welcome letter GYN Patient Medical History Consent for Treatment Form Privacy Notice Registration Form - English Patient Medical History Insurance Verification Consent for Use and Disclosure of PHI
Forms for Adult, OB/GYN & Pediatrics are available for download/printing below. They are available in  (PDF VERSIONS).
Bill of Rights, Responsibilities and Information Patient Registration Form Consent for Use and Disclosure of PHI Bill of Rights, Privacy, Advanced Directive Consent for Treatment of Adult or Minor Privacy Notice Pediatric History-pt Questionaire
Welcome Letter OB Bill of Rights, Responsibilities and Information Adult Medical History CNM Disclosure Letter Notice to the Obstetric Patient Patient Registration Form Consent for Use and Disclosure of PHI Bill of Rights Privacy - Advanced Directives Consent for Treatment of Adult or Minor Privacy Notice
For your convenience, the Adult Forms Packet includes all of the following documents:. 
For your convenience, the GYN Forms Packet includes all of the following documents:. 
For your convenience, the Pediatrics Forms Packet includes all of the following documents:. 
For your convenience, the OBForms Packet includes all of the following documents:. 
Dental
Medical History Form For Dental Patients   
English Spanish English Spanish English Spanish English Spanish English Spanish
GYN Info Packet
English Spanish English Spanish
OB Info Packet