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Patient Intake App

Manager: Ernest Ban-Ira

Company:

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Patient Intake Forms ATC Notes ROI Notes

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CHC New Patient Registration Form

Patient Details

First Name *

Middle Name

Last Name *

Preferred Name *

Month of Birth *

Date of Birth *

Year of Birth *

Social Security Number

Please enter your email address

Email Address

Confirm Email

What type of phone number is your primary phone number? *

Primary Phone Number *

Secondary Phone Number

ext.

Ok to leave voice message?

Do you think of yourself as:
*

What sex were you assigned at
birth on your original birth certificate?
*

Do you think of yourself as: *

Sexual Identity Other

Pronouns to use: *

Pronouns Other

Race *

Ethnicity *

Preferred Language *

Are you a full time student? *

Are you a member of the US Armed Forces (i.e. Air Force, Army, Coast Guard, Navy, National Guard)? *

What is your marital status? *

Street Address *

Street Address 2 (i.e. Apartment Number)

City *

State *

Zip Code *

Are you scheduled for an appointment to receive the monkeypox vaccine? *

How did you hear about us? *

Please type here:

Social Determinants of Health (SDoH)

Have you experienced challenges in any of the following areas over the last 6 months: Transportation, housing, food, utilities, financial/insurance, and/or safety?

If you are looking for support, please complete the following set of questions so that we can determine how to best support you.

At any point in the past 2 years, has season or migrant farm work been your or your family main source of income

Have you been discharged from the armed forces of the United States?

What language are you most comfortable speaking?

How many family members, including yourself, do you currently live with?

What is your housing situation today?

Are you worried about losing your housing?

What is the highest level of school that you have finished?

What is your current work situation?

What is your main insurance?

During the past year, what was the total combined income for you and the family members you live with? This information will help us determine if you are eligible for any benefits. (If you choose not to disclose, write I choose not to answer)

In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? Check all that apply

Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? Check all that apply.

How often do you see or talk to people that you care about and feel close to? (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)

Stress is when someone feels tense, nervous, anxious, or can't sleep at night because their mind is troubled. How stressed are you?

In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?

Would like to be contacted by a member of our Access to Care Team to discuss what supportive resources may be available to you?

If you would like help with food, housing, insurance, transportation or other needs, you can contact 211 by dialing 211 from a phone or by visiting www.211ct.org.

Guarantor Information

Check here to indicate you are your own Guarantor

The Guarantor is the person who should be sent billing statements.

Guarantor First Name *

Guarantor Last Name *

Guarantor Month of Birth *

Guarantor Date of Birth *

Guarantor Year of Birth *

Check here if Address is same as Patient

Address

City

State

Zip Code

Please enter your email address

Guarantor Email

Guarantor Confirm Email

What Phone type is Guarantor Primary Phone? *

Guarantor Primary Phone *

Guarantor Secondary Phone

Ok to leave message? *

Guarantor Relationship *

Emergency Contact Details

Is your guarantor also your emergency contact?

Emergency Contact First Name *

Emergency Contact Last Name *

What Phone type is Emergency contact primary Phone? *

Emergency Contact Phone *

ext.

Emergency Relationship *

Insurance Information

Do you have insurance?

Insurance Provider

Insurance ID Number

Group Number

Effective Date

Expiration Date

Policy Holder's First Name

Policy Holder's Last Name

Please review the following documents

Please click on the Terms and Conditions. to review our policies regarding your personal health information

By checking the box below, I acknowledge that I have read the above documents and received a copy of the Terms and Conditions.

I agree to the document above.

Please sign here: *

Signature Date: *

Please click on the CHC s Notice of Privacy Practices (NPP). to review our policies regarding your personal health information

By checking the box below, I acknowledge that I have read the above documents and received a copy of CHC s Notice of Privacy Practices (NPP).

I agree to the document above.

Please sign here: *

Signature Date: *

Please click on the Consent to treament. to review our policies regarding your personal health information

By checking the box below, I acknowledge that I have read the above documents and received a copy of the Consent to treament.

I agree to the document above.

Please sign here: *

Signature Date: *

Former/Current Healthcare Provider Info

CHC would like to collect your previous medical history and information. By completing an ROI (a Release of Information) below, you may authorize CHC to OBTAIN your info from your previous healthcare office

Would you like to complete a release so that CHC may collect your previous health information? *

Would you like assistance sharing your previous healthcare information?

Who was your healthcare provider?

What is the name of their practice?

Facility Address

Facility Address 2

Facility City

Facility State

Facility Zip

Facility Phone

ext.

Facility Fax

ext.

The type of info to be released or obtained is as follows

Standard Docs Other

If drug/alcohol abuse, psychiatric/mental health, or HIV/AIDS related information is to be included

If you do not wish to disclose all of your drug/alcohol abuse information, please indicate what information to exclude here:

I am signing this authorization for the following reason:

Please explain:

This authorization will expire 90 days from the date on which it was signed, unless I indicate a different expiration event or date here:

Submit

Release Signature

I understand that I have a legal right to revoke this authorization at any time/ I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Community Health Center, Inc. (CHC) Medical Records Department. I understand that the revocation will not apply to information that has already been released in response to his authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations.

I understand authorizing the use or disclosure of the information identified is voluntary. I can refuse to sign this authorization. I need not sign this form to ensure healthcare treatment. I can contact the Privacy Officer if I have questions about my health information.

I understand that by entering my name below, I am signing this Authorization electronically. I agree that my electronic signature is the legal equivalent of a manual signature on this Authorization.

By signing below, I acknowledge that I have read and understand this authorization form and that CHC has 30 days to fulfill my request.

Please check here to complete your release

Release Date

Please type your name to sign the release

Submit

Save

Admin

Signature Name

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