Today’s Patient’s Is this yo Yes Street A P.O. Box Patient O Spouse Name: Guardian Name: Person r Is this pe Occupat Patients Please i Subscrib Name of applicab Patient’s IN CASE Name of The u Date: s Last Name: our legal name? No ddress: x: Occupation: Information: n Information: responsible for b erson a patient h tion: relationship to s ndicate Primary ber’s Name: f Dental and/or ble): s relationship to s E OF EMERGEN f local friend or re e following inform sers of Preferred inf PC14 First: If not, wh INSU ill: Birth ere? Y Employer: subscriber: Sel Insurance Secondary Insu subscriber: Se NCY elative (not living mation is requeste d Family Healthc formation will no 48.00 PAT : M hat is your legal City: Patient Employ Addr Addr RANCE INFOh date: A Yes No Employer lf Spouse Medicare Subscriber’s SS urance (if Sub elf Spouse g at same addres ed by the Federa care dba Clarity H t be used to disc THE P.A.T.C. TIENT REGIST (Pleas PAT Middle: name? yer: ress: ress: RMATION (Ple Address (if differ address: Child S Medicaid SN B bscriber’s name: Child S IN Css): al Government in Healthcare. You criminate against (con H. CENTER TRATION FOR se Print) TIENT INFORM Mr. Ms. Mrs. Miss (Former name): Social Secu ease give your rent): Step Child O Blue Cross Blu Birth Date: Step Child O ASE OF EMER Relationship t n order to monitor are not required you in any way, ntinued on back) Page 1 RM Primary Care MATION Primary Phone : urity Number: State: r insurance ca Other ue Shield Policy # Other RGENCY to patient: r compliance wit d to furnish this in nor will be relea e Provider: e Number: Ema Birth date: Seco Empl Phone Num Phone Num ard to the recPrima Empl United Healthcar Grou Group no.: Primary Phone th Federal laws p nformation, but a ased except in ag ail Address: Age: ondary Phone N ZIP Code: loyer Phone Num mber: mber: eptionist) ary Phone Numb loyer Phone Num re Other p # Poli # Second prohibiting discrim are encouraged t ggregate form. Sex: M F umber: mber: ber: mber: Co-payment: $ cy no.: ary Phone # mination against to do so. This
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THE P.A.T.C.H. CENTER PATIENT REGISTRATION …...ic disease manag arent or guardian hild to receive de livered by a hygie hild to receive co ls and outreach, a hild to be transpo annibal
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Transcript
Today’s
Patient’s
Is this yo
Yes
Street A
P.O. Box
Patient O
Spouse
Name:
Guardian
Name:
Person r
Is this pe
Occupat
Patients
Please i
Subscrib
Name ofapplicab
Patient’s
IN CASE
Name of
The
u
Date:
s Last Name:
our legal name?
No
ddress:
x:
Occupation:
Information:
n Information:
responsible for b
erson a patient h
tion:
relationship to s
ndicate Primary
ber’s Name:
f Dental and/or ble):
s relationship to s
E OF EMERGEN
f local friend or re
e following informsers of Preferred
inf
PC14
First:
If not, wh
INSU
ill: Birth
ere? Y
Employer:
subscriber: Sel
Insurance
Secondary Insu
subscriber: Se
NCY
elative (not living
mation is requested Family Healthcformation will no
48.00
PAT
: M
hat is your legal
City:
Patient Employ
Addr
Addr
RANCE INFOR
h date: A
Yes No
Employer
lf Spouse
Medicare
Subscriber’s SS
urance (if Sub
elf Spouse
g at same addres
ed by the Federacare dba Clarity Ht be used to disc
THE P.A.T.C.TIENT REGIST
(Pleas
PAT
Middle:
name?
yer:
ress:
ress:
RMATION (Ple
Address (if differ
address:
Child S
Medicaid
SN B
bscriber’s name:
Child S
IN CA
ss):
al Government inHealthcare. Youcriminate against
(con
H. CENTER TRATION FORse Print)
TIENT INFORM
Mr. Ms.
Mrs. Miss
(Former name):
Social Secu
ease give your
rent):
Step Child O
Blue Cross Blu
Birth Date:
Step Child O
ASE OF EMER
Relationship t
n order to monitorare not required
t you in any way,
ntinued on back)
Page 1
RM
Primary Care
MATION
Primary Phone
:
urity Number:
State:
r insurance ca
Other
ue Shield
Policy #
Other
RGENCY
to patient:
r compliance witd to furnish this in nor will be relea
e Provider:
e Number: Ema
Birth date:
Seco
Empl
Phone Num
Phone Num
ard to the rece
Prima
Empl
United Healthcar
Grou
Group no.:
Primary Phone
th Federal laws pnformation, but aased except in ag
ail Address:
Age:
ondary Phone N
ZIP Code:
loyer Phone Num
mber:
mber:
eptionist)
ary Phone Numb
loyer Phone Num
re Other
p #
Poli
# Second
prohibiting discrimare encouraged tggregate form.
Sex:
M F
umber:
mber:
ber:
mber:
Co-payment:
$
cy no.:
ary Phone #
mination against to do so. This
Please circle one answer in each of the following categories.
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Race: Other Pacific Islander White (not Hispanic or Latino)
Asian Black/African American Hispanic or Latino (all races)
Native Hawaiian American Indian/Alaska Native Refuse to Report
Primary Language:
English
Other (Specify)
Are you a veteran?:
YES
NO
Housing Status: Transitional Housing
Homeless Doubling Up
Own/Rent Shelter
Marital Status: Divorced
Single Widow
Married Legally Separated
Employment Status:
Patient: Part Full Unemployed
Spouse: Part Full Unemployed
Number Living in Household:
Income: ______________________
Annual Monthly Bi-Weekly Weekly
Does your child qualify for the school lunch program?
Yes No
Insurance and Patient Responsibility
Insurance claims are submitted on your behalf by Clarity Healthcare. If your child is on the HPS Free or Reduced School Lunch program, there will be no cost to you for services provided at the P.A.T.C.H. Center. For children or faculty with insurance, we will file a claim with your insurance and you will be billed for any applicable coinsurance or deductible. Agreement to Pay for Services I authorize Preferred Healthcare dba Clarity Healthcare to release my medical information necessary to Medicaid or my insurance plan to process claims and further authorize payment of medical benefits payable directly to Preferred Family Healthcare dba Clarity Healthcare. Privacy Practice Acknowledgment I am aware that the Clarity Healthcare has a HIPAA (Health Insurance Portability and Accountability Act) Notice of Privacy Practices. I may request a copy at any time by contacting Clarity Healthcare at 573-603-1460 or download a copy at www.clarity-healthcare.org.
The above information is true to the best of my knowledge. I authorize assignment of benefits for services received to be paid directly to Preferred Family Healthcare dba Clarity Healthcare. I understand that I am financially responsible for any balance. I also authorize Preferred Family Healthcare dba Clarity Healthcare or my insurance company to release any information required to process my claims.
Patient/Guardian Signature _________________________________________________ Date ____________________
PC148.00 Page 2
CLA
Full Name ___
Home Addres
Phone #: ____
___ Yes! I coninjuries, vaotherwise
___ Yes! I conSome trea
___ Yes! I concommunit
___ Yes! I con
___ Yes! I conhealth infotwo agencpermitted submitting
Information excabove. The indi
I understand thAbuse Patient Rcannot be disc
I consent to allodeemed necesspayments not chealthcare and
I authorize the rcollection; inclurelease of preaplans, test resucollection (if ap
I also consent tSenior Services
By signing this consent. I unde
_____________Patient or Pare
If you would like
ARITY HEALTH
_____________
ss: ___________
_____________
sent for me / my caccinations, chron specified by the p
sent for me / my catment may be de
sent for me / my cty resource referra
sent for me / my c
sent to allowing Hormation for the pucies is confidential by law. The indivig the request in wr
change by these pividual may not ha
at my alcohol andRecords, 42 C.F.Rlosed without my w
ow Clarity Healthcsary for my physic
covered under insu payment purpose
release of medicading the release odmission, recertifilts, or consultationplicable).
to allow Clarity Hes to that agency an
consent, I confirmerstand I may revo
_______________nt/Legal Guardian
e a copy of this au
HCARE /PREFSha
______________
______________
______________
child to receive menic disease managparent or guardian
child to receive delivered by a hygie
child to receive coals and outreach, a
child to be transpo
Hannibal School Durpose of continuil and will not be diidual or the parentriting to the Super
ersons or agencieave access to certa
/or drug treatmentR. Part 2, and the written consent un
care/Preferred Famcal and mental heaurance benefits foes.
l and billing informof alcohol or drug acation, and appeans. I further author
althcare/Preferrednd to cooperate w
m I am the ___ paoke this consent at
______________n Signature
uthorization, pleas
THE P.AFERRED FAMIared Consent t
_____________
_____________
_ Alternate Phon
edical care througgement, and referrn
ental care through nist or assistant.
unseling and/ or cand coordination o
orted to appointme
istrict #60 and Claty of care and treaisclosed to any otht/guardian (if indivintendent of Scho
es may be used onain services if this
t records are proteHealth Insurance nless otherwise pr
mily Healthcare, Inalth unless otherwr these services. I
mation from Clarityabuse (if applicab
al information to inrize the release of
d Family Healthcawith investigations,
atient / ___ paret any time with a w
_______________
e initial: _____ Ye
A.T.C.H. CENTLY HEALTHCAto Treat and R
______ SSN: __
______________
ne #: _________
h the P.A.T.C.H. Crals) Please note:
the P.A.T.C.H. Ce
case managementof outside resource
ents by HPS. This
arity Healthcare/Pratment. I understaher party without tidual listed above ol.
nly for educationas release of inform
ected under the fePortability and Acrovided for in the
nc. to obtain emergwise specified throu
also give permiss
y Healthcare/Prefele) information thasurance companief DMH69 Standard
re to report comm providing client in
ent/legal guardianwritten request.
_______________
es _____ N
TER ARE AND HA
Record Disclo
______________
____City: _____
_____________
Center (examples all required and r
enter (Examples: c
t services. (Exames and/or services
permission can b
referred Family Heand that all informthe prior written co is a minor) may r
Stomach Issues/Ulcers Specify: Sexual Disease/HIV Specify:Mental Illness Specify: Seizures Specify:
Drug Abuse/Alcoholism Specify: Sinus/Hay Fever Specify:Depression/Anxiety Specify: Thyroid Disease Specify:
Patient Portal User Agreement
Clarity Healthcare provides this site for the exclusive use of its established patients. The patient portal is designed to enhance patient – physician communications and provides access to helpful resources made available to you. At Clarity Healthcare, we strive to keep your information in your records correct and complete. If you identify any discrepancy on your record, you agree to notify us immediately. Additionally, any information that you provide to us, you agree that it is factual and correct information. The patient portal provides the following services to you:
Medication re-fill requests
The ability to ask questions online between office staff, nurses and physicians.
Review Patient’s medical summary, medication list, treatment history and visitation dates.
The ability to request appointments to see your doctor The patient portal is not intended to provide internet based diagnostic medical services. Additionally, the following limitations apply:
No internet based triage and treatment request. Diagnosis can only be made and treatment rendered after the patient schedules and sees the doctor.
This portal is not intended for emergency purposes. If you seek emergency care, please call 911.
No request for narcotic pain medication will be accepted.
Request for re-fill medication not currently being treated by one of our physicians. The patient portal is provided in partnership with NextGen, our Electronic Health Record software and provider. Please read our HIPAA policy for information on how protected health information (PHI) is used at Clarity Healthcare. All new and established patients have signed HIPAA agreement and have been given a copy of our HIPAA policy. If you do not recall signing a HIPAA agreement, please ask our receptionist for a copy for you to review. The patient portal is provided by Clarity Healthcare as a courtesy to our patients. However, if abuse of the patient portal occurs, Clarity Healthcare reserves the right to terminate or suspend user access as directed by administrative personnel. Once you have signed the Patient Portal User Agreement and provided a valid email address, you will be given a copy of our Patient Portal Registration Guide that will assist you in signing up for your account. While our patient portal is user friendly, if you have technical questions, please feel free to call our office during normal business hours at (573) 603-1460. Patient Acknowledgement and Agreement I acknowledge that I have read and fully understand this consent form. I understand that it is my responsibility to keep my password secure to avoid unintended access and to notify Clarity Healthcare if I believe that my account has been compromised. I have been given risks and benefits of patient portal and agree that I understand the risks associated with online communications between my physician and patient and consent to the conditions outlined herein. I acknowledge that using the patient portal is entirely voluntary and will not impact the quality of care I receive from Clarity Healthcare should I decide against using the patient portal. I understand that Clarity Healthcare reserves the right at their discretion to terminate the use of the patient portal or to suspend user access as directed by the administrative personnel. In addition, I agree to adhere to the policies set forth herein, as well as any other instructions or guidelines that my physician may impose for online communications.