REGISTRATION FORM. How would you like to receive health information? Electronic Paper In Person. Daytime Phone Preferred.

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1 Signature Preferred Pharmacy Referral Info Emergency Contact Guarantor Information Patient Information Name (Last, First, MI) REGISTRATION FORM Today's Date Street Address City State Zip Gender M F SSN Cell Phone Preferred Work Phone Preferred Home Phone Preferred Employer Occupation Address Date of Birth Address Martial Status Single Married Divorced Widowed Separated Partner Other How would you like to receive health information? Electronic Paper In Person Is patient also guarantor? Yes No (If no please provide information below) Name Address City State Zip Telephone Relationship to Patient Name Address City State Zip Address Relationship to Patient Daytime Phone Preferred Evening Phone Preferred Primary Care Physician Name (if applicable) Physician Phone/Fax (if known) Physician Address (if known) How did you hear about us? Name Telephone Address By signing below, I attest that the information I provided is correct to the best of my knowledge. Patient Signature: Guarantor Signature (if other than patient): Date: / / Date: / /

2 Insurance Information Name (Last, First, MI) ASSIGNMENT OF BENEFITS Insurance: Yes No Primary Insurance Company Policy # Group # Claims Address (if known) City State Zip Phone Patient's Relationship to Insured Self Spouse Child Other Name of Subscriber (if other than patient) Subscriber's Social Security # Gender M F Date of Birth Secondary Insurance Company Policy # Group # Claims Address (if known) City State Zip Phone Patient's Relationship to Insured Self Spouse Child Other Name of Subscriber (if other than patient) Subscriber's Social Security # Gender M F Date of Birth I hereby authorize direct remittance of payment of all insurance benefits, including Medicare and Medicaid, to Access Community Health Center for all covered services provided to me during all courses of treatment. I understand that I am financially responsible to Access Community Health Center for any charges not covered by insurance. It is my responsibility to notify Access Community Health Center of any changes in my insurance coverage. In some cases exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by Access Community Health Center, and/or my health care insurer if the submitted claims or any part of them are denied for payment. I authorize Access Community Health Center to release/give any information and copies of my medical records needed by my insurance company(ies) to pay Access Community Health Center for their services. I acknowledge that in certain circumstances, insurance company may send a check and/or Explanation of Benefits (EOB) for services provided by Access Community Health Center directly to patient. In such cases, I agree to endorse and send such check and/or EOB to Access Community Health Center. Patient Signature: Guarantor Signature (if other than patient): Date: / / Date: / /

3 ELIGIBILITY DETERMINATION FOR SLIDING FEE DISCOUNTS It is ACCESS Community Health Center policy to provide essential services to all patients regardless of the patient s ability to pay. Discounts are set by the ACCESS Community Health Center consumer Board of Directors and are offered based on the information you provide regarding your family size and income. If you are eligible for a sliding fee discount, it will apply to all services received at ACCESS Community Health Center, but not for those services provided outside the Health Center. Please complete the following information, even if you have insurance. Household Income Before Taxes HOUSEHOLD MEMBER NUMBER MONTHLY INCOME YEARLY INCOME Self Name: Spouse Dependent Children Other dependents Total I am declining to provide information on my income and family size and agree to pay the full ACCESS Community Health Center fee. ACCEPTABLE PROOF OF INCOME IS REQUIRED FOR THE SLIDING FEE DISCOUNT PROGRAM. IF YOUR FINANCIAL SITUATION CHANGES, PLEASE KEEP ACCESS CHC INFORMED. I certify that all information shown above is true, accurate and correct. I understand that if ACCESS Community Health Center determines that I misrepresented or falsified information, I will no longer receive discounts and may be asked to pay back discounts provided. I agree to provide documentation of my income at my next visit. Name (print) Witness: Signature: Date: Staff to complete remaining Eligible for Sliding Fee Discount: Yes No Patient Refused If yes, acceptable proof of income provided: Yes No Patient Refused If insured, health insurance card provided: Yes No Not applicable Patient reports no income Yes Patient is unable to obtain proof from an employer. Yes (This includes paid in cash/off the books earnings) If yes, to either question, please utilize the self attestation form.

4 Welcome to Access Community Health Center. AHRC HEALTHCARE INC. GENERAL CONSENT/PERMISSION FOR TREATMENT Please read this document carefully. Feel free to request discussion or ask questions of your physician before signing. I, authorize the performance of such appropriately indicated physical examination, x-rays, laboratory and other routine diagnostic procedures and treatment as my/the patient s physician or others of Access Community Health Center s medical staff consider to be necessary or appropriate for the purpose of diagnosis or my/the patient s condition. I understand that the nature of and the need for each procedure and treatment will be explained to me before-hand, and that I am free to refuse any one or all procedures or treatments if I so choose. I consent to the diagnostic study and/or disposal by Access Community Health Center authorities of my blood, urine or other body fluids, stool specimens or tissues which are obtained in accordance with routine medical practice and governmental regulation. I further understand that HIV and genetic testing require separate consultation and consent. I further consent to the examination, study and retention of such specimens, and the use of the findings for medical, scientific or educational purposes provided that the confidentiality of my/the patient s identity is maintained. Further, I expect no compensation or other remuneration relating to the use of the findings of investigative studies. I consent to the present and future prescription and/or administration of medicines or drugs listed in the Hospital Formulary of U.S. Pharmacopoeia as may be deemed necessary by my/the patient s physician or others of Access Community Health Center s medical staff in the course of my/the patient s diagnosis and treatment with the understanding that the nature of and the need for such medicines or drugs will be explained to me beforehand, and that I shall always be free to refuse each and all of them if I so choose. I understand that the explanation which will be given to me of the nature, intended purpose, and the reasonable foreseeable risks, consequences, complications, benefits and alternatives of the examination(s), procedure(s) or treatment(s) which may be performed or used in the course of diagnosing or treating my/the patient s condition will not be exhaustive and that other risks and complications may arise but the likelihood of their occurring is not reasonably foreseeable. I have been advised that if I desire a more detailed explanation prior to my consent such explanation will be given to me. I acknowledge that I have received no warranties or assurances with respect to any benefits which are hoped to be realized, or consequences which may result, from any of the examination(s), procedure(s) or treatment(s) which may be performed or used. I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risks of injury and even death. I consent to the photographing and/or videotaping of the appropriate portions of my body, which are pertinent to showing my physical condition, for medical, scientific or educational purposes, provided reasonable precautions are taken to conceal my identity. I understand that under HIPAA, written authorization to release personal health information (PHI) is not required for Access Community Health Center for normal operations for TREATMENT for the patient, processes leading to PAYMENT for services to the patient, and OPERATIONS such as quality assurance, compliance, etc. I acknowledge that I have read this document in its entirety and that I fully understand it prior to my signing. I understand that I am to make any inquiries regarding any aspects of my/the patient s diagnosis or treatment which I do not understand. I represent to my/the patient s physician and Access Community Health Center that I am eligible to give this consent..* Signature of patient/parent/guardian Date Relationship to patient *Note: If the patient is under 18 years of age, the permission of the patient s parent or legal guardian must be obtained, unless the patient has married or is the parent of a child.

5 AHRC HEALTHCARE INC. CONSENT FOR COMMUNICATION VIA (Provider Patient) I, hereby consent to have my physician communicate with me or members of his staff, where appropriate or other physicians, nurse practitioners and pharmacists via regarding the following aspects of my medical care and treatment: Test results Prescriptions Appointments Billing Other: I understand that is not a confidential method of communication. I further understand that there is a risk that communications between my physician and me or members of my physician s office staff, or between my physician and other physicians, nurse practitioners and pharmacists regarding my medical care and treatment may be intercepted by third parties or transmitted to unintended parties. I also understand that any communications between my physician and me or members of his office staff, or between my physician and other physicians, nurse practitioners or pharmacists regarding my medical care and treatment will be printed out and made a part of my medical record. I understand that in an urgent or emergent situation I should call my provider or go to the Emergency Room and not rely on . Patient Name (Print or Type) Signature of Patient or Responsible Party Date Relationship (if responsible party)

6 PATIENT NAME: AHRC HEALTHCARE INC. ACKNOWLEDGEMENT OF RECEIPT OF RIGHTS AND HIPAA NOTICE OF PRIVACY PRACTICES I hereby acknowledge that I have been given a copy of Patients Rights & Responsibilities and the HIPAA Notice of Privacy Practices. I have been given an opportunity to have my questions, if any, answered about this document. By signing below, I acknowledge that I have been provided a copy of the Access Community Health Center Notice of Privacy Practices and have therefore been advised of how medical information about me may be used and disclosed by ACCESS Community Health Center and how I may obtain access to this information. Signature of individual or Relationship to Client Date Guardian or parent (if under 18)

7 AHRC HEALTHCARE INC. Patient Name: PATIENT DATA QUESTIONNAIRE We would like to collect certain information in order to help us improve the quality of our service. You will not be refused service if you choose not to participate, but please help us by answering the following questions: 1) Have you served in the United States military (veteran)? YES NO 2) Are you of Hispanic/Latino ethnicity? YES NO 3) Describe your race (place X in front of selection, choose all that apply) White Native Hawaiian or Other Pacific Islander Black or African American American Indian or Alaska Native Asian Other Race Would prefer not to say 4) Do you prefer to communicate in English or another language? (circle one) If the answer is another language, in what language can we best serve you? English Another Language 5) Do you consider yourself to be a person without a permanent place to live? (living in a shelter, staying with family/friends, etc) YES NO 6) Are you a farmworker? YES NO Migrant Seasonal 7) Are you living in public housing? (government rental assistant program) YES NO 8) How did you hear about us? (place X in front of selection) Self Agency (Non-AHRC) Doctor School Family Hospital Friend Outreach MSC Other Internet Thank you for taking your time to complete this questionnaire.

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