Forms

Notice of privacy practices (PDF) 84K
The E/TFHC’s Notice of Privacy Practices describes how your Protected Health Information (PHI) may be used and/or disclosed by the ETFHC in the course of providing care to you.

Hoosier Healthwise (HH) application (PDF) 68K   |   Instructions for application (PDF) 96K
In order for you to become eligible for Hoosier Healthwise, you must first complete an application. To speed up the approval process, you may print off the attached application and drop off or mail to either Health Center.

Healthy Indiana Plan (HIP) application - English (PDF) 416K  
Healthy Indiana Plan (HIP) application – Spanish (PDF) 732K  

Sliding Fee Scale application (PDF) 48K
In order to become eligible for the E/TFHC’s Sliding Fee Discount Program, you must first complete a Sliding Fee Scale Application. To speed up the approval process, you may print off the attached application and drop off at either Health Center or mail to:

Trafalgar Family Health Center
Attn: Community Health Benefits
14 Trafalgar Square
Trafalgar, IN 46181

Edinburgh Family Health Center
Attn: Community Health Benefits
911 E. Main Cross
Edinburgh, IN 46124