Language
English (US)
Patient Information
Please provide the requested information about the individual that is registering to become a patient.
Date
-
Month
-
Day
Year
Date
Patient Name
*
First Name
Last Name
Patient Name Storage
*
First Name
Last Name
Sex
*
Please Select
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Relationship to Patient and Authorization
Determine who will have access to information concerning medical care, as well as who can bring the patient in for treatment. A Legal Guardian is person who has been court-appointed to care for another person and make decisions on their behalf. A Legal Custodian is a person, other than a parent or guardian, to whom legal custody of the child has been transferred by a court, but does not include a person who has only physical custody of the child.
Relationship to Patient
*
Please Select
Self
Parent
Legal Guardian
Legal Custodian
Is the patient over 18?
*
Please Select
Yes
No
Your Name
*
First Name
Last Name
Allow a family member or friend to bring the child in for treatment?
*
Yes
No
Allow another family member or friend to have access to information concerning medical care?
*
Yes
No
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Designation of Health Care Surrogate for a Minor
All children under the age of 18 need to have the Authorization to Treat A Minor form completed. This form provides Community Health Centers with a list of individuals able to bring the child in for medical or dental treatment.
Additional Parent, Legal Guardian, or Legal Custodian
First Name
Last Name
Relationship to Patient
Please Select
Parent
Legal Guardian
Legal Custodian
(1) Additional Consent
Please list all additional individuals you would like to give consent to bring the child in for medical or dental treatment.
(1) Name of Person to Give Consent
First Name
Last Name
(1) Relationship to Patient
Please Select
Grandparent
Brother / Sister
Family Friend
Teacher
Other
(1) Phone Number
Please enter a valid phone number.
(1) Address
Would you like to add an additional individual?
Yes
No
(2) Name of Person to Give Consent
First Name
Last Name
(2) Relationship to Patient
Please Select
Grandparent
Brother / Sister
Family Friend
Teacher
Other
(2) Phone Number
Please enter a valid phone number.
(2) Address
Notification of Surrogate
I/We will notify and send a copy of this document to the following person(s) other than my/our surrogate, so that they may know the identity of my/our surrogate.
(1) Name of Who to Notify
(2) Name of Who to Notify
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Patient Information Release Consent
There are times when Community Health Centers (CHC), Inc. will need to contact you or when you may wish to allow family members and friends to have access to information concerning your medical care. Other than as allowed by federal law, we will not release any information to any person except as authorized below by you. Consent is valid unless revoked by the patient or legal guardian at any time.
(1) Name of Authorized
*
First Name
Last Name
(1) Relationship to Patient
*
Please Select
Parent
Spouse
Grandparent
Brother / Sister
Family Friend
Other
(1) Phone Number
*
Please enter a valid phone number.
(1) I authorize Community Health Centers to contact, share, or provide information to the individuals named in this consent form.
*
Appointments (dates, location, times, provider, reason)
Treatment (prescriptions, medication refills, diagnosis, procedures, etc)
Test and Procedure Results
Billing and Payment Information
Would you like to add an additional individual?
Yes
No
(2) Name of Authorized
*
First Name
Last Name
(2) Relationship to Patient
*
Please Select
Parent
Spouse
Grandparent
Brother / Sister
Family Friend
Other
(2) Phone Number
*
Please enter a valid phone number.
(2) I authorize Community Health Centers to contact, share, or provide information to the individuals named in this consent form.
*
Appointments (dates, location, times, provider, reason)
Treatment (prescriptions, medication refills, diagnosis, procedures, etc)
Test and Procedure Results
Billing and Payment Information
Would you like to add an additional individual?
Yes
No
(3) Name of Authorized
*
First Name
Last Name
(3) Relationship to Patient
*
Please Select
Parent
Spouse
Grandparent
Brother / Sister
Family Friend
Other
(3) Phone Number
*
Please enter a valid phone number.
(3) I authorize Community Health Centers to contact, share, or provide information to the individuals named in this consent form.
*
Appointments (dates, location, times, provider, reason)
Treatment (prescriptions, medication refills, diagnosis, procedures, etc)
Test and Procedure Results
Billing and Payment Information
Would you like to add an additional individual?
Yes
No
(4) Name of Authorized
*
First Name
Last Name
(4) Relationship to Patient
*
Please Select
Parent
Spouse
Grandparent
Brother / Sister
Family Friend
Other
(4) Phone Number
*
Please enter a valid phone number.
(4) I authorize Community Health Centers to contact, share, or provide information to the individuals named in this consent form.
*
Appointments (dates, location, times, provider, reason)
Treatment (prescriptions, medication refills, diagnosis, procedures, etc)
Test and Procedure Results
Billing and Payment Information
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Insurance and Payment Information
You may qualify for discounted services even if you have health insurance. Discounts are applied to insurance co-pays and deductibles. Qualification is based on the Federal Income levels.
Insurance Status
*
Please Select
With Insurance
Without Insurance
Insurance Name and ID
*
Guarantor Name
*
The guarantor is the person who accepts financial responsibility.
Guarantor Date of Birth
*
-
Month
-
Day
Year
Date
Insurance Address
*
Patient Identification
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Attach a copy of your government issued ID (drivers license, ID card, etc.). For those with insurance, please attach a copy of the front and back of your insurance card.
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of
Sliding Discount Program
You may qualify for discounted services even if you have health insurance. Discounts are applied to insurance co-pays and deductibles. Qualification is based on the Federal Income levels. More information about the Sliding Discount Program can be found in our Resources page.
Would you like to apply for the Sliding Discount Program?
*
Apply: I am providing my income details and I would also like to apply for Community Health Centers, Inc. Medical, Dental and Optometry Sliding Fee Scale program.
Decline: I am providing my income details however; I am declining the option to apply for Community Health Centers, Inc. Medical, Dental and Optometry Sliding Fee Scale Program. (By Declining, I am accepting financial responsibility for the entire bill, including any fees that are not covered by my insurance plan and I agree to pay any balance in full)
Decline: I am declining your request for income details. (By declining to provide income details, I am also declining the option to apply for Community Health Centers, Inc. Medical, Dental and Optometry Sliding Fee Scale program, furthermore, I am accepting financial responsibility for the entire bill, including any fees that are not covered by my insurance plan and I agree to pay any balance in full)
Household Size
*
Please Select
1 (Self)
2
3
4
5
6
7
8
9
10
Annual Household Income
*
After submission of your Patient Intake Form, you will be redirected to our Sliding Discount Program Application Form. You will need to complete this form before you're able to be considered for the program.
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Electronic Signature
I certify that the above facts are true and correct to the best of my knowledge. I am also aware that this information may be randomly audited at any time for verification purposes. Knowingly providing false information may result in termination of services.
Patient Agreement
*
I certify that the above facts are true and correct to the best of my knowledge. I am also aware that this information may be randomly audited at any time for verification purposes. Knowingly providing false information may result in termination of services.
Notices and Agreements
*
I acknowledge by checking this box, that I have read and/or been given access to the Medical/Dental Home Welcome Book, Payment Agreement, Notice of Privacy Practices, Healthcare Advance Directives Policy, Financial Practice and Procedures, and Patients Bill of Rights and Responsibilities.
Authorization for the Treatment of a Minor
*
I (We) being the parent(s)/legal guardian(s) hereby give my permission for the following individual(s) to bring my child to Community Health Centers, Inc for medical or dental treatment. I grant these individuals the ability to consent for any needed medical or dental services as recommended by the provider staff. As these individuals will be acting on my behalf, I also agree to hold Community Health Centers, Inc harmless (will not pursue legal action) for decisions which have been made by the named individuals regarding my child’s health care. I understand I can revoke this consent at any time.
Consent to Treat & Information Release
*
(1) I voluntarily hereby consent to CHC, Inc. to provide evaluation, treatment, and therapy as deemed necessary, including obtaining external prescription information. I authorize CHC, Inc. to release appropriate information concerning immunizations to schools for admittance as required by law and to the following: Social Security, the Centers for Medicare and Medicaid or its intermediaries (Medicaid/Medicare), or any other insurance compensation carrier for billing purposes. (2) I understand that it is mandatory to notify CHC, Inc. of any other party who may be responsible for paying for the patient above. (3) I authorize CHC, Inc. to release to my insurance carrier and its agents any information concerning health care, advice, treatment, supplies provided or supplies needed to determine these benefits or the benefits payable for related services. (4) I authorize the provider to make X-rays, study models, photographs or any other diagnostic aids deemed appropriate to complete a thorough diagnosis of the patient’s needs. I also understand that all X-rays and diagnostic aids are the property of CHC, Inc. and that requested copies will be made available for a reasonable fee as allowed by law. (5) I further authorize the provider to choose and employ assistance as deemed appropriate. I also understand that the use of anesthetic agents embodies a potential risk. (6) I understand that I may receive messages from CHC via telephone, text, and email. If you would like to opt out at any time, please contact a CHC team member. Standard text and data rates may apply. (7) The above information is true and I promise to notify CHC, Inc. of any changes in my medical history as soon as they occur.
Signature
*
Clear
All notices and agreements can be download from our
Patient Resources
page.
Consent Alignment Field (IGNORE)
Submit
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