Patient Registration Form

Please complete to the best of your knowledge. For areas that do not apply to the patient please enter “N/A”.Patient’s Name First MI Last Date of Birth (DOB) MM/DD/YY

Under 18?Mailing Address Street City State Zip County

Physical Address Street Same as Mailing City State Zip County

1st Phone Cell

HomeWork

2nd Phone CellHome

Work

Email

Emergency Contact: Name Relationship Phone

Marital Status Single Married Separated Divorced Widowed Domestic Partner

Guarantor’s Name First MI Last

Same as Patient (parent/guardian) DOB: (Parent or guardian if applicable)

Guarantor’s Address Street City, State, Zip

Social Security # / Tax ID Relationship Phone

__________- HomeChild or Minor lives with: Employer Work Phone

- -

# of People inHousehold EXAMPLE: $0 - $11,8801 $0 – $11,880 $11,881 - $17,820 $17,821 – $23,760 More than $23,7612 $0 – $16,020 $16,021 - $24,030 $24,031 - $32,040 More than $32.041

3 $0 – $20,160 $20,161 - $30,240 $30,241 - $40,320 More than $40,321

4 $0 – $24,300 $24,301 - $36,450 $36,451 - $48,600 More than $48,601

5 $0 – $28,440 $28,441 - $42,660 $42,661 - $56,880 More than $56,881

6 $0 – $32,580 $32,581 - $48,870 $48,871 - $65,160 More than $65,161

Patient Registration FormDisclosures and Consents

Preferred Language:Are interpreter services needed? Yes NoRace (check all that apply) Asian White American Indian/Alaska Native Black/African American Native Hawaiian Refuse to Provide Other Pacific Islander

Sexual Orientation:Heterosexual LesbianGay or homosexual BisexualOtherUnknownDecline to answer

Ethnicity Hispanic/Latino Non-Hispanic/Latino Refuse to provideWhat sex were you assigned at birth? Female Male Decline to answer

Homeless Status:

Doubling Up StreetShelter Not homelessTransitional Unknown

Gender Preference:MaleFemaleTransgender Male from FemaleTransgender Female from MaleGender non-conformingOtherPreferred Gender Pronoun ____Preferred Name:

________________________

Public Housing Projects? Yes No Are you a Veteran? Yes No Migrant Worker’s Status? Yes No

How did you hear about us? Family/ Friend Shelter Health Dept. Hospital Media Social Services Other

Does the patient have Medical Insurance? Please present your insurance card to the Medical Receptionist.Yes No if no, please skip to the Sliding Fee Scale Questionnaire to apply for our discount fee program.

Please circle the range below indicating your estimated annual household income according to the number of people living in your home. Advance Community Health is required to report this information to the Federal government, and it helps us to better understand the needs of the communities

we serve. No identifying information shall be disclosed in any of our required reports. Your anonymity is protected.

Please list your Pharmacy Information:Pharmacy Name: ______________________________________________________________________________________________________________________Pharmacy Address: ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________Pharmacy Telephone Number: _______________________________________________________________________________________________________________

Effective 4/1/2016 and Updated 4/1/2016

Patient Name: ______________________________________________ Date of Birth: ______________________ First MI Last ASSIGNMENT OF INSURANCE BENEFITS:I hereby authorize direct payment of my insurance benefits to Advance Community Health for services rendered to my dependents or me by the practitioner. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any co-pay or balance due that Advance Community Health is unable to collect from by insurance carrier for whatever reason.

MEDICARE/MEDICAID/CHAMPUS INSURANCE BENEFITS:I certify that the information given by me in applying for payment under these programs is correct. I authorize the release of any of my or my dependents records requested by these insurance carriers. I hereby direct that payment of me or my dependents authorized benefits be made directly to Advance Community Health on my behalf. I understand that my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes release of information to the insurer or agency shown. It is my responsibility for deductible, coinsurance, and non-covered services. AUTHORIZATION TO RELEASE NON-PUBLIC PERSONAL INFORMATION:I certify that I have received and read a copy Advance Community Health Privacy Practice of the date on the signature below. I hereby authorize Advance Community Health to release any of my or my dependents medical or incidental non-public protected health information as described in the privacy practices that maybe necessary for medical evaluation, treatment, consultation, or the processing of insurance benefits. I understand that I retain the rights granted to me through Advance Community Privacy Practices. I hereby consent to Advance Community Health’s Privacy Practices.

AUTHORIZATION TO MAIL, CALL OR E-MAIL:I certify that I understand the privacy risks of the mail, phone calls, and e-mail. I hereby authorize an Advance Community Health or my practitioner to mail, call, or e-mail me with communications regarding my healthcare, including but not limited to such things as appointment reminders, referral arrangements, and laboratory results. I understand that I have the right to rescind this authorization at any time by notifying Advance Community Health to that effect in writing. I hereby authorize the designated parties below to request and receive the release of any protected health information regarding my treatment, payment, or administrative operations. I understand the identity of designated parties must be verified before the release of any information. I also understand these parties will have access to all of my protect health information including substance abuse, mental health, STI, AIDS, and HIV records.

NAME: __________________________________________________________________ RELATIONSHIP: _________________________

NAME: __________________________________________________________________ RELATIONSHIP: _________________________

LAB/X-RAY/DIAGNOSTIC SERVICES:I understand that I may receive a separate bill if my medical care includes lab, x-ray, or other diagnostic services. I further understand that I am financially responsible for co-pay or balance due for these services if they are not reimbursed by my insurance for whatever reason.

CONSENT TO TREATMENT:I hereby consent to evaluation, testing, and treatment as directed as Advance Community Health practitioner. Patient Signature: ___________________________________________________ DATE: _________________________

Guarantor Signature: ________________________________________________DATE: _________________________ (If different from patient)

Patient/Guarantor Signature: ___________________________________________ DATE: ________________________ (Please Print)

Effective 4/1/2016 and Updated 4/1/2016