If you have questions about how much your fee will be, you may stop by or call with your income information before your appointment.

Transcription

1 238 Arsenal Street, Watertown, NY Family Practice Office: (315) Fax: (315) Adult Office: (315) Fax: (315) Dental Office: (315) Fax: (315) N. State Street, Lowville, NY Lowville Medical & Dental Office: (315) Fax: (315) Dear New Patient: Welcome! Thank you for trusting us with your healthcare. North Country Family Health Center is a Federally Qualified Health Center. We offer medical, behavioral health, and dental care to both children and adults, no matter what their income. We are available to you when you need us, offering same day appointments when necessary and a way to reach us even when our office is closed. We ask you to be on time for your appointments. If you can t come to a scheduled appointment, please let us know as soon as possible, so that we can offer that appointment slot to another patient. Because our appointments are in high demand we have a policy of confirming your appointment a day or two before you are scheduled to come in. Please help us by letting us know that you are coming if we have left you a reminder message. We participate with a number of insurance providers including Medicaid, Medicare, and many Medicaid Managed Care programs. A current list of the insurance companies with which we participate is available on our website: If you are covered by an insurance plan we accept please read your policy benefits before your appointment to learn what your insurance will cover and what you are expected to pay. If your insurance plan calls for a co-pay at the time of your visit, please be ready to pay this amount when you check in. If you have questions about your benefits, please call your insurance company. If you are covered by an insurance plan we do not accept, you will be responsible for payment on the day of your appointment. We will give you the information you need to send to your insurance company in order for them to pay you. If you have NO insurance we have staff to help you find affordable insurance coverage. You may also be eligible for a reduced fee based on your income (information about our reduced fee schedule is part of this packet). If you have questions about how much your fee will be, you may stop by or call with your income information before your appointment. We look forward to getting to know you and helping to keep you and/or your children healthy. Please call us at the number listed at the top of this form if you have any questions.

2 Patient Registration Form Date Rec d Staff Initials Staff use: Medical Dental PATIENT INFORMATION First Name: Middle Name: Last Name: Other name you prefer to be called? Date of Birth: Sex (at birth): Social Security Number: Marital Status: Male Female Single Married Divorced Separated Widowed Other Street Address: City: State: Zip: Phone #1: Phone #2: Home Work Cell Message Home Work Cell Message Address: Current Primary Care Physician (PCP): Mother s Maiden Name (Pediatric Patients ONLY) May we you with appointment information/reminders? Yes No May we text your cell with appointment information/reminders? Yes No Language: Race Ethnicity English Español Other: Native American/Alaskan White I need language translation services I need a sign language interpreter Black/African-American Asian Assistance Needed? Multi-Racial Native Hawaiian Other Pacific Islander Hispanic/Latino/Latina Not Hispanic/Latino/Latina BILLING/INSURANCE INFORMATION (Who is responsible for your bill?) Mr. Mrs. Ms. First Name Middle Initial Last Name Suffix Date of Birth Relationship to Patient *Proof of legal status required for treatment Patient (if 18 years or older) Parent Custodial Parent* Guardian* Foster Parent* Street Address City State Zip Social Security Number Phone #1 Phone #2 Home Work Cell Leave Message Home Work Cell Leave Message MEDICAL Insurance Information I do not have Medical Insurance I would like to apply for a Reduced Fee (see pages 6-8) I have Medical Insurance: Insurance Company Name: Medical Policy Number: Billing Address for Insurance: DENTAL Insurance Information I do not have Dental Insurance I would like to apply for a Reduced Fee (see pages 6-8) I have Dental Insurance: Insurance Company Name: Dental Policy Number: Billing Address for Insurance: Policy Holder s Name: Policy Holder s SS Number: Policy Holder s Date of Birth: Policy Holder s Employer: Policy Holder s Name: Policy Holder s SS Number: Policy Holder s Date of Birth: Policy Holder s Employer: I have additional Medical Insurance: Secondary MEDICAL Insurance Information Insurance Company Name: Policy Holder s Name: Same as above Billing Address for Insurance: Policy Holder s Date of Birth: Policy Number: Preferred Pharmacy: Pharmacy Name Pharmacy Address Revised Oct 2016 EG

3 Patient Registration Form We need the following information to help our staff to understand you better, choose the right s Date Rec d Staff Initials We need the following information to help understand you better, to choose the right screenings and care for you, to use the most respectful language when talking to you, and to fulfill grant requirements. The choices for some of these questions came from our funders and we understand that some of them may not capture your individual identity. We respect that this information is personal and confidential. Please help us serve you by choosing the best answers to these questions. ALL OF THE FOLLOWING QUESTIONS REFER TO THE PATIENT (not the Parent or Caregiver) Family Financial Information: Employment Status: For Agricultural Workers: Family Household Size: Household Income: $ Employed Self Employed Occupation: Employed year-round Move to find work Retired Farm worker a week a month a year Military Service: Are you a Veteran? Yes No Gender Identity Male Female Do you think of yourself as: Straight Unemployed Retired Transgender (Female to Male) Transgender (Male to Female) Lesbian or Gay Bisexual Student Doesn t Apply (N/A) Other Something else Preferred Pronoun He She Housing: Where did you sleep last night? In my house/apartment In a shelter Car Do not have a place With a friend/relative Who do we need to talk to about patient care? Who takes care of the patient? (Medication, Appointments, Follow up) Name Relationship to Patient Phone No One. I take care of myself. Emergency Contact(s) Same caregiver listed above We would call this contact if you become very sick or need assistance while you are here or if we had important information about your health and couldn t reach you Call 1 st Name: Relationship to Patient Phone Call 2 nd Name Relationship to Patient Phone Health Care Proxy and Advance Directives for patients 18 or older or those who are emancipated A Health Care Proxy gives someone else the power to make medical decisions for you when you can t speak for yourself. Do you have a Health Care Proxy? Yes No Advance Directives are written or oral instructions relating to how health care is to be provided when an adult becomes incapacitated and unable to make decisions on their own. Examples of Advance Directives: MOLST, DNR, and Living Will Do you have an Advance Directive? Yes No CONSENT FOR TREATMENT To be completed by the patient or the patient s legally authorized representative/parent: I consent to dental treatment, medical treatment, electronic prescription history and diagnostic evaluation, including HIV testing, for myself or for the patient for whom I am the parent or legally authorized representative. I also understand that I may opt out of HIV testing at any time. I understand that the Health Center will share patient health information according to federal and state law for treatment, payment, and operations. NCFHC has engaged Night Nurse, Inc. as our after-hours triage call center. I understand that all calls into the call center are recorded to improve customer service and patient care by having an actual record of the call. Your signature on this form serves as consent for you and your minor children. It may be revoked at any time with written notice to NCFHC who shall notify Night Nurse. Signature of Patient: Date: Signature of Legally Authorized Representative: Relationship to Patient: Date: Revised Dec 2016 EG

4 Patient Policies & Consents TO BE REVIEWED ANNUALLY Understanding our finance policies is an important part of your care and treatment. A complete description of those policies is available at the front desk and on our website. If you have any questions, please ask our staff. Finance Policy North Country Family Health Center serves all patients whether they are covered by insurance or not. Discounts for services are offered depending upon household size and income. You may apply for a discount at the front desk. When you use our services, you are responsible for the cost of those services. If you have insurance: We will bill your insurance for you, including Medicaid, CHP/FH, and private insurances. You will be responsible for any co-pays, cost shares and deductibles, or non-covered services. If you qualify, our sliding fee scale can be applied to any remaining balance. If you do not have insurance: We offer a sliding fee scale based on household size and income. I have read and understand the NCFHC Finance Policy. I authorize my insurance provider to pay North Country Family Health Center, Inc. for services rendered. Signature of Patient: Date: Signature of Legally Authorized Representative: Relationship to Patient: Date: HIPAA COMPLIANT PATIENT CONSENT FORM In accordance with New York State law and the Health Insurance Portability and Accountability Act of 1996 North Country Family Health Center (NCFHC) staff is prohibited from speaking with any individual other than you regarding any of your protected health information (PHI). This includes information regarding your condition, medication, appointments, or test results. You have the right to give consent so that PHI may be disclosed allowing staff to carry out your treatment plan, obtain payment, and conduct healthcare operations. The NCFHC Notice of Privacy Practices provides a more complete description of the law and health information disclosures. Patients have the right to view this notice and copies are available in our office. I authorize the release of information including the diagnosis, medical records, examination results rendered to me and medical bill/claims information for primary care, behavioral health, dental care, alcohol and drug abuse treatment and/or confidential HIV related information. By authorizing the release of behavioral health, alcohol and drug abuse treatment and/or confidential HIV related information the recipient is prohibited from re-disclosing the information unless permitted under state or federal law. The information may be released to: Print Name Relationship to Patient Phone Number Print Name Relationship to Patient Phone Number NCFHC may call: home work cell phone If there is no answer, NCFHC may: Leave a message asking for a return call Leave a detailed message Please leave only the following information: I have read and understand all of the above information. I authorize NCFHC to disclose my PHI and complete my treatment plan. My treatment, payment, enrollment in a health plan or eligibility for benefits will not be conditioned upon my authorization of this disclosure. I further understand this consent is good for up to 12 months from date of signature unless indicated by a termination date ( /20 ). Signature of Patient or Representative/Guardian Date Printed Name of Patient Signature of Witness Date Printed Name of Witness EPG 12/2014

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6 Information about how you can REDUCE the cost of your visits As a Federally Qualified Health Center it is our mission is to make sure patients can afford the healthcare they need. That is why we offer qualified patients a Sliding Fee Discount. Our sliding fee discount is for anyone whose household income is at or below 200% of the Federal Poverty Guidelines. Household includes all people living in the same house or apartment even if they are not related to you. After you fill out the Sliding Fee Scale Application we can tell you how much we can discount your fee. We can use this discount for any amount due and for any services we offer. It can take up to 2 weeks to process completed applications. Your application is considered pending until you receive written notice that it has been approved. We will give you the care you need no matter what you can pay. How to apply for our sliding fee discount: Our front desk staff can help you apply. Step one, asking about your household size and income, is always done as part of check-in. To apply for a discount you must fill out a short form and show us proof of income. If you don t have proof of income on your first visit, we can give you 30 days to bring in one of the documents listed below. Your application can t be approved until we have all of the paperwork we need. What you need to bring for proof of income : If you are EMPLOYED: a copy of last year s income tax return OR a W-2 (If you did not file a return) OR pay stubs from last 30 days OR written statement from your employer If you are NOT EMPLOYED: Proof of Social Security income Proof of Unemployment income Proof of Disability income Proof of other income (if you have it) like child support, alimony, or pension We will ask you to update your Sliding Fee Application every year. 2/2018

7 *Because dental care is often more expensive to provide, North Country Family Health Center uses slightly different Sliding Fee Schedules for medical and dental programs Sliding Fee Schedule - Medical Flat Fee Per Visit 100% 125% 150% 175% 200% Over 200% A $15.00 B $30.00 C $45.00 D $60.00 E $ % Family Size 1 $12,140 $15,175 $18,210 $21,245 $24,280 $24,281 2 $16,460 $20,575 $24,690 $28,805 $32,920 $32,921 3 $20,780 $25,975 $31,170 $36,365 $41,560 $41,561 4 $25,100 $31,375 $37,650 $43,925 $50,200 $50,201 5 $29,420 $36,775 $44,130 $51,485 $58,840 $58,841 6 $33,740 $42,175 $50,610 $59,045 $67,480 $67,481 7 $38,060 $47,575 $57,090 $66,605 $76,120 $76,121 8 $42,380 $52,975 $63,570 $74,165 $84,760 $84,761 9 $46,700 $58,375 $70,050 $81,725 $93,400 $93, $51,020 $63,775 $76,530 $89,285 $102,040 $102,041 Additional $4,320 $5,400 $6,480 $7,560 $8, Sliding Fee Schedule - Dental Percentage of Federal Income Guidelines Flat Fee Per Visit 100% 125% 150% 175% 200% Over 200% A $15.00 B $40.00 C $60.00 D $80.00 E $ % Family Size 1 $12,140 $15,175 $18,210 $21,245 $24,280 $24,281 2 $16,460 $20,575 $24,690 $28,805 $32,920 $32,921 3 $20,780 $25,975 $31,170 $36,365 $41,560 $41,561 4 $25,100 $31,375 $37,650 $43,925 $50,200 $50,201 5 $29,420 $36,775 $44,130 $51,485 $58,840 $58,841 6 $33,740 $42,175 $50,610 $59,045 $67,480 $67,481 7 $38,060 $47,575 $57,090 $66,605 $76,120 $76,121 8 $42,380 $52,975 $63,570 $74,165 $84,760 $84,761 9 $46,700 $58,375 $70,050 $81,725 $93,400 $93, $51,020 $63,775 $76,530 $89,285 $102,040 $102,041 Additional $4,320 $5,400 $6,480 $7,560 $8,640

8 North Country Family Health Center, Inc. Sliding Fee Discount Program Application I am applying for a Discounted Fee for Medical Care Dental Care Both Responsible Person Today s Date: Patient Name First Name: Middle: Last: Date of Birth: Home Address: City: State: Zip: Mailing Address: City: State: Zip: Home Phone #: ( ) Cell Phone #: ( ) Social Security # Do you have insurance? No Yes If Yes, What Insurance: Marital Status: Single In a relationship Married Divorced Separated Widowed OTHER PEOPLE in your household: Name Date of Birth Social Security Number Employment Income Name Amount How Often? Employer: You $ Week Month Year Spouse $ Week Month Year Children $ Week Month Year Other $ Week Month Year $ Week Month Year TOTAL $ Week Month Year Other Income You Spouse Children Other How Often? Social Security $ $ $ $ Week Month Year Public Assistance $ $ $ $ Week Month Year Retirement Pension $ $ $ $ Week Month Year Disability $ $ $ $ Week Month Year Child Support/Alimony $ $ $ $ Week Month Year Interest Income $ $ $ $ Week Month Year Other $ $ $ $ Week Month Year NOTE: To comply with federal regulations, in order to give you a discount on our services, it is necessary for us to ask some personal questions. Your answers will be kept on file and in strict confidence. You must verify your income at least every year. For Office Use Only: Approved Denied Household Size: Adjusted Gross Income: MEDICAL DENTAL A $15 A $15 B $30 B $40 C $45 C $60 D $60 D $80 E $75 E $100 Approval Signature: Date: I do hereby swear or affirm that the information provided on this application is true and correct to the best of my knowledge and belief. I agree that any misleading or falsified information, and/or omissions may disqualify me from further consideration for the sliding fee program and will subject me to penalties under Federal Laws which may include fines and imprisonment. I further agree to inform North Country Family Health Center if there is a significant change in my income. If acceptance to the sliding fee program is obtained under this application, I will comply with all rules and regulations of North Country Family Health Center. I hereby acknowledge that I read the foregoing disclosure and understand it. Date: Name (Please Print): Signature: Note: Your application is considered PENDING until you receive written confirmation from North Country Family Health Center 2/2018 AF