If Minor, Mother /Guardian name Father. Street Address City State. Social Security Home Phone Sex M F. Emergency Contact Person(Name) Cell Phone#

Transcription

1 Account #, Inc. Registration Form Thank you for choosing our practice for your health care needs. Patient Information Name First MI Last Birthdate If Minor, Mother /Guardian name Father Street Address City State Zip Code Social Security Home Phone Sex M F Employer Phone Address City State Emergency Contact Person(Name) Cell Phone# Responsible Party Name of Gurdian responsible for the account SSN# Relationship to Patient Home Phone# Work Phone Demographics Are you (circle one) Minor Married Divorced Widow Single Separated Family size (circle one) Family Income Weekly Bi-Weekly Monthly Individual Income Weekly Bi-Weekly Monthly Number of Children Race Asian Black Native American White Native Hawaiian Pacific Islanders More than one race Other Veteran (Circle one) Yes No Hispanic Identity (circle one) Hispanic Non- Hispanic Migrant (Circle one) Yes No Seasonal Farm Worker Yes No Preferred Language English Spanish Other: Migrant (Circle one) Yes No Seasonal Farm Worker Yes No Education Level (Circle one) High School Diploma College Degree Some High Scchool Some College GED Highest Grade Completed Additional Persons to Consent for Medical Care of Minors I give the named Individual listed below my full permission to seek medical care including but not limited to injections, laceration repair, prescriptions, general medical care and emergency medical care for my child as the situation warrants: Name: Phone: Name: Phone: Name: Phone: Name: Phone: Relationship: Relationship: Relationship: Relationship: Office use only Signature(Patient/Legal Guardian)

2 HIPAA - AUTHORIZATION TO RELEASE/MEDICAL INFORMATION TO INDIVIDUALS/FAMILY MEMBERS In accordance with Federal government privacy rules implemented through the Healthcare Portability Act of 1996 (HIPAA), in order for your healthcare provider or staff of to discuss your condition with members of your family or other individuals that you designate, we must obtain your authorization prior to doing so. In the event of a critical episode or if you are unable to give your authorization due to the severity of your medical condition, the law stipulates that these rules may be waived. I do not authorize to release any or all information concerning my (Initial) medical care to any individual except as set forth above. I authorize to verbally release any or (Initial) all information concerning my medical care to the following individuals: Name Name Name Relationship to Patient Relationship to Patient Relationship to Patient Print Patient Name of Birth Social Security # Patient /Legal Guardian Signature Witness Signature Contact Methods, Inc. is allowed to leave voic s/text message with the telephone numbers on the patient registration form regarding patient information: Yes No For communication, I understand that if this is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I still elect to receive communications: Yes No Patient/Legal Guardian Signature: : Acknowledgement of Receipt of Notice of Privacy Practices & Patient Rights & Responsibilities Patient Name: I have received a copy of the Notice of Privacy Practices & Patient Rights & Responsibilities for the above named practice. Patient/Legal Guardian Signature: : Official Signature of Notary, Notary Public Notary's printed or typed name My Commission expires

3 Authorization to obtain Private Health Information Patient Name DOB Address City State Zip Code Phone No. Social Security No. I hereby authorize: Name Phone No. Fax No. To release my medical record as indicated below to: Attention: Medical Records: Please use this form as your coversheet 324 North Queen Street Kinston, N.C Telephone No. (252) Fax No. (252) Information to be released: s History of Physical Exam Progress Notes Lab Reports X-ray Reports Other (Specify) Entire Medical Record Purpose of Disclosure: Changing Physician Insurance Consultation/Second Opinion Legal Continuity of Care Moving Other (Specify) I specifically authorize the Release of Information relating to: Substance Abuse (including alcohol/drug) Mental Health (including psychotherapy notes) HIV related information (AIDS related testing) Signature of Patient or Legal Guardian 1. I understand that this information will expire one year for the date I have signed this form, unless otherwise specified. 2. I understand that I may revoke this authorization at any time by notifying the providing organization, in writing, and it will be effective on the date notified except to the extent action has already been taken upon it. 3. I understand the information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by Federal Privacy regulations. 4. I understand that my health care and payment for my health care will not be affected if I do not sign this form. Signature of Patient or Legal Guardian Signature of Witness

4 KINSTON COMMUNITY HEALTH CENTER, INC. PATIENTS RIGHTS AND RESPONSIBILITIES INTRODUCTION, Inc. (KCHC) patients have a fundamental right to consider care that safeguards their personal dignity and respects their cultural, psychosocial, and spiritual values. The organization provides information in a manner tailored to the patient s language and ability to understand. KCHC has written policies on patient rights and privacy practices with the purpose to improve quality care by emphasizing patient s rights and responsibilities and to ensure care is provided in an ethical manner. PATIENT RIGHTS 1. The patient has the right to affordable medical treatment regardless of race, religion, gender, national origin, marital status, age, or disability. 2. Privacy and also has the right to access, request amendment to and obtain information on disclosures of his or her health information, in accordance with law and regulation. 3. Confidentiality of his or her medical records. A patient may or may not approve the release of any information in the medical records, to insurance companies or other doctors, except when this is required by law. Original charts are considered the property of KCHC. 4. Be treated with dignity and respect. The staff respects the patient s mental, social, spiritual, and cultural values about health, illness, and injury. 5. Know what his or her illness is; to know treatment options, the advantages and the disadvantages of each; to help make decision about the treatment that he or she may receive; and to know that complications the treatment is likely to cause in a language that is easily understood by the patient. 6. Receive from his provider information necessary to give informed consent prior to the start of any procedure and/or treatment. Patients who are unable to fully participate in treatment decisions have the right to be represented by parents, guardians, family members, or other conservators. 7. Refuse treatment to the extent permitted by the law and to be informed of the medical consequences of his actions. 8. Expect that within its capacity KCHC must make a reasonable response to the request of the patient for services. KCHC must provide evaluation, service, and/or referral as indicated by the urgency of the case. 9. Obtain information as to the relationship of KCHC to any other health care and educational institutions as his or her case is concerned. 10. Expect reasonable continuity of care. He or she has the right to know in advance what appointment times and providers are available. 11. Examine and receive an explanation of his or her bill regardless of the source of payment. 12. Know what KCHC rules and regulation apply to his or her conduct as a patient. 13. Be fully informed about the services available at KCHC. 14. Be fully informed about the provisions made for non-business hour emergency coverage. 15. Voice grievances and recommend changes in polices and services. 16. Consult with another provider. 17. Be given the names, qualifications, and experience of provider s and other KCHC staff who are directly involved with the patient s medical care. 18. Be advised of nay teaching or research to be performed by KCHC that may affect the patient s care. A patient has the right to refuse to participate in any such projects. 19. The appropriate assessment and management of pain.

5 KINSTON COMMUNITY HEALTH CENTER, INC. PATIENT RESPONSIBILITIES 1. The responsibility of the patient will be to keep appointment and notify the KCHC in advance when unable to keep the appointment. 2. Follow the medical provider plan of care. 3. Seek clarification when necessary to fully understand your health problem and the proposed plan of care. 4. Provide complete accurate information about your identity, demographics, insurance and answer other reasonable questions that will assist KCHC in providing appropriated care and obtaining payment. This includes reviewing and signing all necessary consent, financial agreements or totter documents required by the facility. 5. Bring Medicaid or Medicare card and any other insurance cards at each visit. 6. Provide accurate information about your present illness, medication, past medical or health history including any hospitalizations or any changes in your condition. 7. Supervise your children, both inside and outside the facility. Parents will be held responsible for the actions of their children. Children under 12 should not be left unsupervised. 8. Mange financial arrangements regarding your medical bill at the time of service. 9. Conduct yourself in a courteous, friendly. And respectful manner toward fellow patient and members of the staff. Threatening, violent, abusive, disruptive or loud behaviors are not tolerated. KCHC reserves the right to ask the patient, family, and guest to leave or be removed from the property. 10. Comply with no alcohol, drugs, and/or weapons on the premises. Anyone who arrives at the center under the influence of alcohol, illicit drugs and unauthorized use of controlled substances and does not require urgent care will be asked to leave. Law enforcement may be contacted for assistance. PATIENT FINANCIAL RESPONSIBILITES 1. The patient is financially responsible for any services received at KCHC that are not covered by an insurance company, Medicaid, Medicare, or any other commercial insurance that has been chosen to pay for the services provided at each visit. 2. The amount of the visit will be determined after the Doctor s visit. The cost of each visit may vary depending on what is ordered during my visit. 3. As a courtesy to the patient, KCHC will file your insurance and get authorization for procedures. However, it is your responsibility to give us all the necessary insurance information at the time of service. You may also want to verify with your insurance company that approval was given. KCHC will need a copy of your insurance card at each appointment. 4. If insurance authorization cannot be obtained, you are responsible for the charges. 5. Co-payment is due ate each appointment and before any procedure is performed. 6. KCHC is not a free clinic and we must collect from all of our patients in order to continue to provide services to our community. 7. If referral is needed by your primary doctor, please bring it with you or have the doctor to fax to our office prior to your visit.

6 Notice of Privacy Practices 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. If you have any questions, please contact our privacy office at the address or phone number at the bottom of this notice. This Privacy Notice is being provided to you as a requirement of federal law, the Health Insurance Portability and Accountability Act (HIPPA). This privacy notice describes how we may use and disclose your protected health information(phi) to carry out treatment, payment or healthcare operations(tpo) and for other purposes permitted by law. Protected healthcare information means any written, electronic and oral health information and demographic data that can be used to identify you. Who will follow this notice? provides health care to our patients in partnership with other professionals and health care organizations. The information privacy practices in this notice will he followed by: * Any healthcare professional who treats you at any of the following locations. Lenoir Memorial Hospital While each of these facilities and affiliates operates independently, they may share your health information for coordination of care, treatment, payment and healthcare operations purposes. Our pledge to you: We understand that medical information about you is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. This notice applies to all of the records of your care generated by any of the separate facilities and providers described above. We are required by law to: Keep medical information about you private; Give you this notice of our legal duties and privacy practices with respect to medical information about you; and Follow the terms of the notice that is currently in effect. How we may use and disclose medical information about you: We may use and disclose medical information about you without your prior authorization for treatment (such as sending medical information about you to a specialist as part of a referral) (this includes psychiatric or HIV information if needed for purposes of your diagnosis and treatment); to obtain payment for treatment (such as sending billing information to your insurance company or Medicare); and to support our healthcare operations (such as comparing patient data to improve treatment methods or for professional education purposes) (Note: only limited psychiatric or HIV information maybe disclosed for billing purposes without your authorization). If you are treated in a specialized substance abuse program, your special authorization will be needed for most disclosures other than emergencies). Other examples of such uses and disclosures include contacting you for appointment reminders and telling you about or recommending possible treatment options, alternatives, health-related benefits or services that may be of interest to you. We may also contact you to support our fund making efforts. We may use or disclose medical information about you without your prior authorization for several other reasons. Subject to certain requirements, we may give our medical information about you, without prior authorization for public health purposes, abuse or neglect reporting, health oversight audits or inspections, medical examiners, funeral arrangements and organ donation, workers' compensation purposes, emergencies, national security and other specialized government functions, and for members of the Armed Forces as required by Military Command authorities. We also disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders or other legal process. Under certain circumstances, we may use and disclose health information about you for research purposes, subject to a special approval process. We may also allow potential researchers to review information that may help them prepare for research, so long as the health information they review does not leave our facility, and so long as they agree to specific privacy protections. CONTINUED ON REVERSE SIDE

7 CONTINUED FROM FRONT If admitted as an inpatient, unless you tell us otherwise, we will list in the patient directory your name, location in the hospital, your general condition (good, fair, etc.) and your religious affiliation, and may release all but your religious affiliation to anyone who asks about you by name. Your religious affiliation may be disclosed only to clergy members, even if they do not ask for you by name. We may disclose medical information about you to a friend or family member whom you designate or in appropriate circumstances, unless you request a restriction. We may also disclose information to disaster relief authorities so that your family can be notified of your location and condition. Other uses of Medical Information: In any other situation not covered by this notice, we will ask for your written authorization before using or dis closing medical information about you. If you choose to authorize use or disclosure, you can later revoke that authorization by notifying us in writing of your decision. Right to Access and or Amend Your Records: In most cases, you have the right to look at or get a copy of medical information that we use to make decisions about your care, when you submit a written request. If you request copies, we may charge a fee for the cost of copying, mailing, or other related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision. If you believe that information in your record is incorrect or that important information is missing, you have the right to request that we correct the records, by submitting a request in writing that provides your reason for requesting the amendment. We could deny your request to amend a record if the information is not maintained by us; or if we determine that your record is accurate. You may submit a written statement of disagreement with a decision by us not to amend a record. Right to an Accounting: You have the right to request a list accounting for any dis closures of your health information we have made, except for uses and disclosures for treatment, payment, and healthcare operations, circumstances in which you have specifically authorized such disclosure, and certain other exceptions. To request this list of disclosures, indicate the relevant period, which must be after April 14,2003, but in no event for more than the last six years. You must submit your request in writing to the Privacy Office listed below. Right to Request Restrictions: You may request, in writing, that we not use or disclose medical information about you for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We will consider your request and work to accommodate it when possible, but we are not legally required to accept it. We will inform you of our decision on your request All written requests or appeals should be submitted to the Privacy Office listed below. Requests for Confidential Communications: You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to use to communicate with you. Right to request a paper copy of this Notice: You may receive a paper copy of this Notice from us upon request, even if you have agreed to receive this notice electronically. Changes to this Notice: We may change our policies at any time. Changes will apply to medical information we already hold, as well as new information after the change occurs. Before we make a significant change in our policies, we will change our notice and post the new notice in waiting areas, exam rooms, and on our Web site at You can receive a copy of the current notice at any time. The effective date is listed at the end. Copies of the current notice will be available each time you come to our facility for treatment. You will be asked to acknowledge in writing your receipt of this notice. Complaints: * If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact the Privacy Office listed below. If you are not satisfied with our response, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. Our Privacy Office can provide you the address. Under no circumstances will you be penalized or retaliated against for filing a com plaint. Privacy Officer 324 North Queen St Kinston, NC

8 KINSTON COMMUNITY HEALTH CENTER FOLLOWS A STRICT PRESCRIPTION DRUG POLICY. ANY REFILLS OR NEW PRESCRIPTIONS ARE AT THE DISCRETION OF THE KINSTON COMMUNITY HEALTH CENTER MEDICAL EXPERTS. YOU MAY BE ASKED TO TAKE A BLOOD OR URINE SCREENING TEST PRIOR TO PRESCRIPTIONS BEING WRITTEN. THANK YOU! KINSTON COMMUNITY HEALTH CENTER TEAM

9 Please bring ALL Medications with you to each appointment! Thank you

10 Offers Discounts through our Slide Fee Discount Program. Please contact one of our eligibility specialists for most details! ofrece descuenta por medio de nuestra Programa De Escala De Descuenta. Por favor por mas detalle contactar una de nuestro Especialista De elegibilidad!

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12 KINSTON COMMUNITY HEALTH CENTER, INC. SLIDING FEE DISCOUNT PROGRAM APPLICATION Account Number Patient Name FAMILY SIZE HOW TO COMPLETE THIS FORM What is your total family size? Name INCOME Wages Total Income Wage Frequency Relationship Social Security Retirement Alimony Child Support FAMILY SIZE A family is defined as anyone receiving more than 50% of their support from a head of household, List name and relationship for each person included in total family size above in the list to the left. INCOME Patients must bring required information for verification of family size and income at their first visit in order to qualify for the SFSD. Enter income for each person listed in the family list in the table below under the correct type. Interest Income Public Assistance Other Income I understand that the information I provide on this form is subject to verification by, Inc. I certify that the above information is true and correct to the best of my knowledge and that I understand and agree to adhere to all terms and conditions of the Sliding Fee Discount Program. Applicant Signature Employee Witness Signature ATTACH ALL SUPPORTING DOCUMENTS USED TO DETERMINE FAMILY SIZE AND INCOME

13 INCOME CALCULATION WEEKLY INCOME WEEKLY INCOME AMOUNT X 52 = BI-WEEKLY INCOME BI-WEEKLY INCOME AMOUNT X 26 = MONTHLY INCOME MONTHLY INCOME AMOUNT X 12 = ACCEPTABLE SUPPORTING DOCUMENTATION Family Size Verification Documentation Birth Certificate Income Tax Return Listing Dependents Social Security Card Government Issued Photo ID Passport Driver's License Medicaid Card Other Verifiable Legal Documents Income Type Verification Documentation Wages Social Security Verification Form SSI Benefit Verification Letter Retirement Account Payments Retirement plan statement. Alimony Divorce Decree Child Support Court Order Interest Income Bank Statement Public Assistance Program(s) DSS Benefit Notice/Letter Other Income - Rental Income Form Line 22, Form 1040a Line 15 Other Income - All Other Verifiable Written Documentation