The McGregor Clinic Inc. Patient Registration/Demographic Form. Patient Enrollment PLEASE USE LEGAL NAME

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1 The McGregor Clinic Inc. Patient Registration/Demographic Form Patient Enrollment PLEASE USE LEGAL NAME First Name: MI: Last Name: of Birth: Sex: SS#: Marital Status: Single Married Separated Divorced Widowed Race: White Black or African American Asian American Indian or Alaska Native Native Hawaiian or Pacific Islander Other Ethnicity: Non-Hispanic Hispanic Driver s License #: Physical Address: City, State, Zip: Mailing Address: City, State, Zip: Home Phone: Cell Phone: Work Phone: Ext: Contact Authorization Primary Contact Method Preferred: Home Cell Work Is it OK for us to leave a voic ? Yes No Would you like reminder calls about your appointments? Yes No Primary Insurance Information Insurance Name: Member ID#: Group #: Policy Holder s Name: Policy Holder s DOB: Sex: Policy Holder s SS #: Relationship to Policy Holder: Secondary Insurance Information Insurance Name: Member ID#:

2 Current Pharmacy Information Pharmacy Name: Pharmacy Address: Emergency Contact Information Name: Relationship: Home Phone: Cell Phone: Work Phone: Ext: The Emergency Contact information will only be used in the even that a release cannot be signed due to a medical emergency. A consent to share information must be signed and on file for any other correspondence with the person listed about. Family Information Spouse s Name DOB Child 1 Name DOB Child 2 Name DOB Child 3 Name DOB Other Information Preferred language: English Spanish Creole Portuguese Other: Referral Source: Health Dept. Website Friend/Relative ER/Hospital Family Health Centers Source of Light and Hope Transfer from: Other: Agricultural Status: Migrant Worker Seasonal Worker N/A Signature: :

3 INITIATION OF SERVICES PART I CLIENT PROVIDER RELATIONSHIP CONSENT Client Name: Name of Agency: Agency Address: McGregor Clinic, Inc Broadway Avenue Fort Myers, FL I consent to entering into a client-provider relationship. I authorize The McGregor Clinic, Inc. and their representatives to render routine health care. I understand routine health care is confidential and voluntary and may involve medical office visits including obtaining medical history, examinations, administration of medications, laboratory tests and/or minor procedures. I may discontinue the relationship at any time. PART II DISCLOSURE OF INFORMATION CONSENT (treatment, payment or healthcare operations purposes only) I consent to the use and disclosure of my medical information; including medical, dental, HIV/AIDS, STD, TB, substance abuse prevention, psychiatric/psychological, and case management; for treatment, payment and health care operations. PART III MEDICARE PATIENT CERTIFICATION, AUTHORIZATION TO RELEASE, AND PAYMENT REQUEST (Only applies to Medicare Clients) As Client/Representative signed below, I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize the above agency to release my medical information to the Social Security Administration or its intermediaries / carriers for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician s services to the above named agency and authorize it to submit a claim to Medicare for payment. PART IV ASSIGNMENT OF BENEFITS (Only applies to Third Party Payers) As Client/Representative signed below, I, assign to the above named agency all benefits provided under any health care plan or medical expense policy. The amount of such benefits shall not exceed the medical charges set forth by the approved fee schedule. All payments under this paragraph are to be made to above agency. I am personally responsible for charges not covered by this assignment. PART V RIGHTS MY SIGNATURE BELOW VERIFIES THE ABOVE INFORMATION AND RECEIPT OF THE NOTICE OF PRIVACY Client/Representative Signature Self or Representative s Relationship to Client Witness (Optional) PART VI WITHDRAWAL OF CONSENT I, WITHDRAW THIS CONSENT, effective (). Client/Representative Signature Witness (Optional) Client Name: ID#: DH 3204, 11/08 Original To File; Copy To Client DOB:

4 THE McGREGOR CLINIC "... giving voice to patient choice." PATIENT RIGHTS, RESPONSIBILITIES AND GRIEVANCE PROCEDURE RIGHTS You have the right to receive timely, respectful, high quality services without regard to age, ethnicity, gender, disability, religion, sexual orientation, values and beliefs, and marital status. You have the right to request copies of all signed documents and have access to your medical records. You have the right to participate in the development of your plan of care. You have the right to choose the provider and the type of services and care required within the scope of clinical responsibility. You have the right to receive current information and education about the disease, the medicines and treatment. You have the right to appeal decisions with which you do not agree and to file a patient grievance. You have the right to request an interpreter to enhance communication. We suggest the arrangements be made well enough in advance. You have the right to refuse recommended treatment plans as allowed by law based upon the patient s judgment of risks and benefits and without pressure or unwanted influence from your health care provider. RESPONSIBILITES You are responsible to conduct yourself in a courteous and respectful manner and also to respond in a timely manner to all your appointments. You are responsible for keeping all appointments. You are responsible for notifying your provider if any illness interferes with scheduled appointments. You are responsible for working with your health care provider to develop a plan of care. You are responsible for providing any and all necessary documentation needed to assist in enrolling you in any eligible programs or services. You are responsible for following the instructions of your health care provider to the best of your ability. You may be responsible for a portion of the costs of your health care services. You are responsible for notifying your health care provider of any changes such as address and financial eligibility. GREIVANCE PROCEDURE If you are dissatisfied with the services you are receiving, you may voice a complaint or grievance to your health care provider. If you are not satisfied with the results, you may, within 30 days, submit your concerns in writing to the McGregor Clinic, Inc. Board of Directors. The Board of Directors is responsible in resolving issues in any manner they see fit with the solution being presented to the patient in writing. You have 10 days to appeal the Board s decision. I have had the opportunity to discuss and I am fully aware of the Rights, Responsibilities and Grievance Procedures outlined above. Patient Signature Witness 3487 Broadway Fort Myers, FL Phone: (239) Fax: (239)

5 The McGregor Clinic, Inc. Discounted/Sliding Fee Application It is the policy of The McGregor Clinic, Inc., to provide essential services regardless of the patient s ability to pay. Discounts are offered based upon patient s family income. Please complete the following information and return to the front desk. The discount will apply to all services received at this clinic, but not those services which are purchased from outside, including medications, x-rays, hospitalizations, or other unauthorized services. In the hope that your financial situation approves, discounts apply only to current year. Re-evaluation of your financial need will be completed annually. Earned Family Income Employer 1 Gross Monthly Income $ Employer 2 Gross Monthly Income $ Total Earned Income $ Unearned Income Child Support $ Alimony $ Social Security Unemploy/Worker s SSI/SSD $ Comp $ Other $ Total Unearned Income $ Total Monthly Income Total of Earned Income and Unearned Income $ Household Size Family Size No. of Dependent children living in household I certify that the income information shown is correct. Copies of tax returns, pay stubs, and other information verifying income may be required before a discount is approved. Name (Print) Signature

6 THE McGREGOR CLINIC "... giving voice to patient choice." Client Name DOB SSN AUTHORIZATION TO DISCLOSE CONFIDENTIAL MEDICAL INFORMATION Florida law requires that information contained in medical records be held in strict confidence and not be released without your written authorization. The authorizations designated on this page will remain in effect until you request in writing that your authorization be withdrawn, which you may do at any time. You have a right to receive a copy of all parts of this authorization upon your request. Section 1 Authorization for Release of Medical Information I,, do hereby authorize to release to the following for the purpose of disease management and continuing care, or for its use in determining a claim for such diagnosis or treatment. This may include any and all information pertaining to payment. Information to be disclosed (Initial Sections): General medical records created at The following information from the medical record Records obtained from the following providers STD Records Psychiatric/psychological information/records TB Records HIV/AIDS records Drug/alcohol treatment records Consent to fax/mail Section 2 - Medicare Patient Certification, Authorization to Release and Payment Request (only applies to Medicare Clients) As Client/Representative signed below, I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize the above agency to release my medical information to the Social Security Administration or its intermediaries / carriers for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician s services to the above agency and authorize it to submit a claim to Medicare for payment. Section 3 Consent to Share Information As Client/Representative signed below, I hereby authorize the McGregor Clinic, Inc., and any practitioner examining or treating me to share information with, in order to maintain continuity of care. Information may include psychiatric/psychological, alcohol/drug abuse, sexually transmitted disease, tuberculosis, HIV/AIDS, adult or child abuse information including any information received from other healthcare providers concerning diagnosis and treatment. Section 4 Assignment of Benefits (only applies to Third Party Payers) As Client/Representative signed below, I, assign to the above named agency all benefits provided under any health care plan or medical expense policy. The amount of such benefits shall not exceed the medical charges set forth by the approved fee schedule. All payments under this paragraph are to be made to above agency. I am personally responsible for charges not covered by this assignment. Redisclosure: I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal privacy laws or regulations. Conditioning: I understand that completing this authorization form is voluntary. I realize that treatment will not be denied if I refuse to sign this form. Revocation: I understand that I have the right to revoke this authorization any time. If I revoke this authorization, I understand that I must do so in writing and that I must present my revocation to the medical record department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company, Medicaid and Medicare. Client/Representative Signature Representative s Relationship to Client Witness (Optional)

7 THE McGREGOR CLINIC "... giving voice to patient choice." Acknowledgement of Receipt of Notice of Privacy Practice By signing below, I acknowledge that I have been provided a copy of McGregor Clinic, Inc. Notice of Privacy Practices and have therefore been advised of how my health information may be used and/or disclosed, and how I may obtain access to and control this information Signature of Patient (or Authorized Personal Representative) Print name of Patient (or Authorized Personal Representative) Authority of Personal Representative (e.g.., parent. Legal guardian, health care Surrogate) DOCUMENTATION OF FAITH EFFORTS TO OBTAIN ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES The patient presented for his/her service on this date and was provided a copy of The McGregor Clinic, Inc. Notice of Privacy Practices (Notice.). A good faith effort was made to obtain a written acknowledgement of receipt of the Notice. However, an acknowledgement of receipt was not obtained because of the following reason (s): Patient refused to sign the Acknowledgement of Receipt. Patient was unable to sign or initial the Acknowledgement of Receipt. There was a medical emergency, and an attempt will be made to obtain an Acknowledgement of Receipt at the next available opportunity. Signature of employee completing the form Print name of employee

8 State of Florida Department of Health CONSENT FORM CONFIDENTIAL HUMAN IMMUNODEFICIENCY VIRUS (HIV) TEST HIV testing is a process that uses FDA-approved tests to detect the presence of HIV, the virus that causes AIDS and to see how HIV is affecting your body. The most common type of HIV test detects antibodies produced by the body after HIV infection. Test results are highly reliable but a negative test does not guarantee that you are healthy. Generally, it can take up to three months for HIV antibodies to develop. This is called the window period. During this time, you can test negative for HIV even though the virus is in your body and you can give it to others. A positive antibody HIV test means that you are infected with HIV and can also give it to others even when you feel healthy. Other tests can detect the presence of virus in your blood, measure the amount of virus in your blood, measure the number of T- cells in your blood, or see if the virus is susceptible to HIV/AIDS medications. Some of these test may require a second specimen to be obtained for further testing. Generally, test results will be available in about 2 weeks. If you consent by filling out and signing this form a specimen will be taken and you will be tested. If a rapid HIV test is used, results will be available the same day. If the rapid test detects HIV antibodies, it is very likely that you are infected with the virus, but this result will need to be confirmed. You will be asked to submit a second specimen for further testing. The results from this confirmatory test will be available to you in about 2 weeks. If you test positive, the local health department will contact you to help with counseling, treatment, case management and other services if you need them and want them. You will be asked about sex and/or needle-sharing partners, and voluntary partner counseling and referral services (PCRS) will be offered to you. The HIV test result will become part of your confidential medical record. If you are pregnant, or become pregnant, the test results will become part of your baby s medical record. Finding HIV infection early can be important to your treatment, which along with proper precautions, help prevent spread of the disease. If you are pregnant, there is treatment available to help prevent your baby from getting HIV. If you have any questions, please ask your counselor, physician, or call the Florida AIDS Hotline (1-800-FLA-AIDS or ) before signing this form. CONSENT GIVEN REQUIRED YES NO Initial Here Client must initial the consent statement and then sign below. The consent form must be dated and witnessed. I have been informed about HIV testing and its benefits and limitations. I understand that some tests require a second specimen to be taken from for further testing. Signature of Client or Legal Representative Client s Printed Name Witness Signature Legal Representative s Relationship to the Client (If Applicable) OPTIONAL YES NO Initial Here If Applicable If I move out of the area or live somewhere else, I want my results forwarded to the appropriate public health care provider or the physician listed below so I may be informed of my results and receive posttest counseling. Preferred Physician or Facility and their Mailing Address Instructions: 1. Please ensure that clients read and understand the information provided on this consent form. If clients are unable to read or understand this information, the counselor should read it to them. 2. The client must initial each of the two consent statements as appropriate and sign and date the bottom of the form. 3. If a legal representative of the client signs the consent form, their relationship to the client must be indicated on the appropriate line. 4. In accordance with state protocol, if the client wants their results forwarded, the STD Program Manager will handle the transaction. 5. All consent forms must have a witness signature. The counselor conducting the pre-test counseling can serve as the witness. DH1818, 05/05. (Obsoletes 03/04 edition which may not be used) Stock Number:

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