Submit Resources

Together with our partners, Confidential & Covered is collecting forms, protocols, and tools that health centers use to ask patients about income, insurance coverage, and their confidentiality needs, as well as written policies and procedures for obtaining and using this information. These may include:

  • Intake forms for new or returning patients;
  • Patient income verification forms and policies;
  • Forms that collect visit-specific information (e.g. encounter form, CVR, or superbill);
  • Scripts that staff use to screen patients for insurance coverage, income, and confidentiality; 
  • Internal policies and procedures regarding billing as it relates to confidentiality.

If you have any of the described documents, please use the form below to share them with Confidential & Covered. Submitted documents should be blank.

Confidential & Covered Submission Form

Biographical Information
Material Ownership
Please indicate if you or your agency is a primary author/creator or if you are suggesting this resource on behalf of another individual or organization.
Describe The Material
Why is this resource suitable for the Tools Inventory?
Is the Material Available Online?
Send Material(s)

If the material is not available online, please email your files to