CONSENT FOR CHARITY CARE ACKNOWLEDGEMENTS. Christ Clinic requires proof of income at your first appointment. Please bring 1 of the following:

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1 CONSENT FOR CHARITY CARE I,, acknowledge that the physicians and staff of Christ Clinic are volunteer health care providers and are not administering care for or in expectation of compensation. I also understand that as volunteer health care providers, the physicians and staff of Christ Clinic are immune from any civil liability for any act or omission resulting in death, damage or injury as the volunteer acts are in good faith and in the scope of his/her duties within the organization in providing the health care services. PATIENT/GUARDIAN SIGNATURE DATE ACKNOWLEDGEMENTS I have received and reviewed the following from Christ Clinic (please check): Patient Rights & Responsibilities Notice of Privacy Rights By signing this, I am fully aware of both documents and agree to the information provided in each. PATIENT/GUARDIAN SIGNATURE DATE Christ Clinic requires proof of income at your first appointment. Please bring 1 of the following: 3 most recent pay check stubs Copy of current year Tax return Letter from employer stating monthly income Social security or Disability forms or denial letters Patient/Guardian Signature OFFICE USE ONLY DESIGNATION TO RELEASE CONFIDIENTIAL MEDICAL INFORMATION In accordance with Federal government privacy rules, a written release is required to allow another person access to your medical records. This release grants permission to the clinics listed below to: make or confirm appointments, have access to x-rays and laboratory findings, be informed of your medication, and be made aware of your diagnosis, prognosis, and treatment plans. I give permission to contact the clinics listed below: Access Health Christ Clinic West Houston Clinic (Spring Branch) Other: PATIENT/GUARDIAN SIGNATURE DATE

2 CHRIST CLINIC RIGHTS & RESPONSIBILITES Welcome as a patient to Christ Clinic. Our mission is to provide you and your family with not only quality healthcare, but care and compassion. In order to fulfill our mission, the following rights and responsibilities have been established to assure our purpose can be met. You have the right: To be treated with the utmost respect and dignity no matter their ethnicity, gender, religion or income. To health care and treatment that is reasonable for your condition and within our capability. To make decisions about your health care while discussing it with your provider. To refuse treatment, care and services allowed by the law while understanding the risks that could occur with this refusal. To personal privacy and confidentiality during interviews, examinations and treatment. Please review the Notice of Privacy Rights for more information about this right. To access your medical records. To speak to someone on the management team if you have a complaint. You are responsible: To treat the Christ Clinic staff with the same respect and dignity as allowed to them. Christ Clinic s Executive Director and/or Clinic Director reserve the right to refuse service to anyone acting in an inappropriate manner. To comply with medical recommendations To provide Christ Clinic with accurate information about your financial status and resources as well as any changes that may occur. This includes having Medicaid, Medicare, CHIP, Gold Card or another form of insurance. To contribute $20 on your visit. We accept cash only. To give payment for any diagnostic testing is due at the time of the scheduled service. You will be made aware of the exact fees at the time of your appointment. We accept cash only. To provide only valid Social Security numbers on your patient information sheet. To respect the privacy of other patients while at the clinic. Please keep cell phones off and your family and visitors coming with you to a minimum. To supervise your children at all times. Unattended minors are not allowed in the waiting room. You are responsible for their safety and protection while visiting Christ Clinic.

3 CHRIST CLINIC NOTICE OF PRIVACY RIGHTS THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY. The Health Insurance Portability & Accountability Act of 1996 ( HIPAA ) is a federal program that requires all medical records and other individually identifiable protected health information (PHI) used or disclosed by us in any form, whether electronically, on paper, or orally, to be kept confidential. You have rights to understand and control how your health information is used. We are required to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to PHI We may use and disclose your medical records without authorization only for the following purposes: Treatment: providing, coordinating, or managing health care and related services by one or more health care providers. We may disclose your information to doctors, nurses and other health care personnel who are involved in your care. Health Care Operations: for appointment and patient recall reminders. Also includes the business aspects of running our practice, such as conducting clinic improvement activities, employee training, auditing functions, cost-management analysis and customer service. An example would be an internal quality assessment review. When Required To Do So By Federal, State Or Local Law This may include the following: 1) business associates; 2) to avert a serious threat to health or safety; 3) public health risks; 4) health oversight activities; 5) judicial and administrative procedures; 6) specific government functions; 7) research and organ donation; 8) coroners and funeral directors; and 9) communications with caregivers and relatives. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the management team. The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. The right to inspect and copy your protected health information. Written request is needed. The right to amend your protected health information. The right to receive a list of how your protected health information was disclosed other than treatment, payment or health care operations, as listed above. You have the right to file written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint. If you have any questions or to make a request regarding the rights described above, please contact: Christ Clinic Management Team 5504 First Street Katy, TX (281) For more information about HIPAA or to file a complaint: The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington, D.C (202) or Toll Free:

4 PATIENT INFORMATION Name Date of Birth Age (Nombre) (Fecha de Nacimento) (Edad) Address Street (Calle) Apt. City (Ciudad) State (Estado) Zip Code (Codigo Postal) County (Condado) Home Phone (Telefono de Casa) Cell Phone (Telefono de Cellular) Guardian (Guardian) Phone (Telefono) Relationship ( Relacion) Guardian (Guardian) Phone (Telefono) Relationship ( Relacion) Emergency Contact (Contacto de Emergencia) Phone (Telefono) Relationship (Relacion) Emergency Contact (Contacto de Emergencia) Phone (Telefono) Relationship (Relacion) Social Security No. (Seguro Social #) Gender (Sexo): Male Female Marital Status (Estado Civil) Single (Soltero/a) Married (Casado/a) Divorced (Divorciado/a) Widowed (Viudo/a) Separated (Separado/a) Race: (Raza) White (Blanco) Black/African-American (Negro/Africano Americano) Amer. Indian/Alaska Native (Indio Americano/Esquimal) Native Hawaiian/Pacific Islander (Indigena Hawaino/Isles del Pacifico) Asian (Asiano) More than one race (Mas de una raza) Unreported/Refused (No declarada/se nego a reporter) Ethnicity (Etnicidad): Hispanic/Latino (Hispano/Latino) Non-Hispanic/Latino (No Hispano/Latino) Unreported/Refused (No declarada/se nego a reporter) Are you? ( Es usted?) U.S. Citizen (Ciudadano de E.U.A) Yes (Si) No If not, what country are you from? ( No, de que pais eres?) OR U.S. Resident (Residente de E.U.A) Yes (Si) No Work Permit (Permiso de Trabajo) Student Visa (Visa de estudiante) Asylum or Refugee (Asilo o refugiado) Patient Employment Status (Empleo de Paciente) Full Time (Tiempo Completo) Part Time (Medio Tiempo) Unemployed (Desempleado) Disabled (Desabilitado) Student (Estudiante) Not in Labor Force (No en la Fuerza Laboral) If you do not work, who is the household income contributor? (Si usted no trabaja, quien gana los ingresos de la casa?) Primary Language ( Primer idioma): English (Ingles) Spanish (Espanol) English & Spanish ( Ingles y Espanol) English & Other (Ingles y Otro) Other (Otro) Current or Highest Grade Level of Education (Cual es su nivel mas avanzado de educacion?) Do you have a religion/ spiritual belief that you practice? (Tiene usted alguna religion que practica?) Yes (Si) No If yes, please specify (Si practica una, cual es?): Who were you referred by? (Fue Referido por?) : Memorial Herman Katy Hospital Methodist Hospital West Texas Children s Hospital Or how did you find out about Christ Clinic? (Como se entero acerca de la Clinca de Cristo)? IF Christ Clinic weren t available for you today, would you have to go to the hospital for treatment? ( Yes No Si Christ Clinic no hubiera estado aquí hoy día, usted hubiera tenido que ir al hospital para tratamiento? Sí No

5 MONTHLY HOUSEHOLD INCOME AND HOUSING INFORMATION (Ingresos Mensuales Y Informacion de Vivienda) Total Dollars Received Each Month for Entire Household--Source of Income (Ingresos totales recibidos al mes en la casa) Wages/Salary (Fuentes de Ingresos) Unemployment (Desempleo) $ $ Social Security ( Seguro Social) $ Child Support (Manutencion de los hijos) $ Workmen s Comp (Compensacion de Accidentes de Trabajo) $ Other (Otro Ingreso) $ Disability (Descapacidad) $ TOTAL Monthly HOUSEHOLD Income (Ingreso Total de Vivienda-por mes) $ Did you file income tax last year? ( Usted declarro impuesto el ano pasado?) Housing (Casa): Own (Propietario) Rent (Renta) Stay with friend or family (Vive con familia/amigos) Shelter (Casa Hogar) Homeless (Sin hogar) Other ( Otro) Total number of ADULTS living in the household ( Numero de ADULTOS en el domicilio) Total number of CHILDREN under 18 years in the household ( Numero de MENORES en el domicilio) Any child under 18 year uninsured? (Hay algun niño menor de 18 que no tiene seguro medico?) Yes (Si) No Is there anyone in your household who is pregnant? ( Hay alguien en su hogar que este embarazada?) Yes No PATIENT COVERAGE INFORMATION ( Do you have or receive?) Do you have a doctor you see on a regular basis? (Tiene un doctor regular?) Yes (Si) No If yes, name of doctor/clinic (Si, sí, cual es el nombre del doctor o clinica?) How many times have you visited the Emergency room in the last year? (Cuantas veces has visitado la sala de emergencia en el ultimo año?) Do you have insurance? (Tiene Seguro Medico?): Yes No If yes, name of insurance company (Si, sí, cual es el nombre del seguro?) Medicare: Yes (Si) No Medicaid: Yes (Si) No If no, must show denial letter ( Si no, debe mostrar la carta de comprobante) CHIP: Yes (Si) No If no, must show denial letter ( Si no, debe mostrar la carta de comprobante) Gold Card (Tarjeta Dorada): Yes (Si) No If yes, last date of application (Si, sí, la fecha de la ultima aplicacion): (Harris Health System) ARE YOU OR A FAMILY MEMBER RECEIVING SERVICES FROM AGENCIES MENTIONED BELOW? AGENCY/PROGRAM CLIENT/FAMILY MEMBER RECEIVING/NEEDS REFERRAL/APPLIED MEDICAID/MEDICARE WAIVER PROGRAMS MENTAL HEALT H SERVICES WOMENS, INFANTS, AND CHILDREN (WIC) SUPLEMENT NUTRUTION ASSISTANCE PROGRAM (SNAP)/ OR TEMPORARY ASSISTANE FOR NEEDY FAMILY (TANF) SUPPLMENT SECURITY INCOME(SSI)/ OR SOCIAL SECURITY DISBAILITY INSURANCE (SSDI) SERVICES FOR BLIND AND/OR VISUALLY IMPARIED MEDICAL OTHER AGENCIES ( Otras Agencias) I have read the information provided and answered accordingly. To the best of my knowledge the information above is true and accurate. (He leído la información proporcionada y respondió en consecuencia. Al mejor de mi conocimiento la información anterior es verdadera y exacta.) Patient/Guardian Signature (Firma del paciente) Date (Fecha)

6 DESIGNATION TO RELEASE CONFIDIENTIAL MEDICAL INFORMATION I, give Christ Clinic authorization to release information to for continuity of care. I hereby authorize the use or disclosure of my health information as described above. In accordance with Federal government privacy rules, a written release is required to allow another person access to your medical records. Yo,, doy autorización Cristo Clínica a divulgar información a,, para la continuidad de la atención. Por la presente autorizo el uso o la divulgación de mi información de salud como se describe anteriormente. De acuerdo con las reglas de privacidad del gobierno federal, se requiere una autorización escrita para que otra persona tenga acceso a sus registros médicos. Patient/Guardian Signature (Firma del paciente) Date (Fecha) ASSISTANCE PROVIDED STAFF USE ONLY- USO DE LA CLINICA SOLAMENTE REFERRALS NEEDED ADDITIONALCOMMENTS:

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