CHSSA Form

Instructions For Receiving Forms

Please Read this information as our process has changed.
Please Note - At your annual Well Care visit you can request that your provider push a form to the My Health Connection Patient Portal. There is no charge for printing forms from your portal.
1. Payment is required prior to receiving your form.
2. Regardless of the method you choose to request a form, pre payment will be collected prior to submission.
3. If after reviewing your form request, we determine that payment is not necessary, you will be refunded.
4. Please select your turn around time below.
5. Add your credit card information
6. Complete the Form Request Information including how you would like the form returned.
7. Once our Medical Records Department has reviewed and completed your form, they will email you with the encrypted form attached.
8. If you have elected to pick up your form, you will receive an email letting you know its ready for pick-up at our East Elizabeth Office.

My Products*

7-10 Day Turnaround

$10.00

Next Business Day Turnaround

$40.00

Total

$0.00

Form Completion Information

Please complete the information below indicating your contact information, relationship to patient, how you would like to receive your form and you preferred method of delivery.
Person Requesting Form*

First NameLast Name
Relationship To Patient*
Contact Phone*
Please enter a valid phone number.
Contact Email
example@example.com
How Would You Like To Receive Your Form?*

Please Read

Per the CHSAA sports form, Page 4 of the form is the only required documentation needed for sports participation. Please be aware that this is the only part of the 4-page sports form that will be completed and returned by our office.

Page 4

PREPARTICIPATION PHYSICAL EVALUATION (Page 4 of 4)
SUBMIT THIS MEDICAL ELIGIBILITY FORM TO THE SCHOOL

This form is valid for 365 calendar days from the date signed below.
MEDICAL ELIGIBILITY FORM

Student Information (to be completed by student and parent)
Students Full Name
Gender
Age
Date Of Birth
School
Grade In School
Sports
Home Address
City State
Home Phone
Name Of Parent or Guardian
Email
example@example.com
Person To Contact In Case Of An Emergency
Relationship To Student
Emergency Contact Cell Phone
Work Phone
Other Phone
Family Healthcare Provider
City, State
Office Phone

Instructions For Receiving Forms