Fordland Clinic, Inc

Child Patient Information and Consent Form

Welcome to Fordland Clinic. We are a not-for-profit community health center, and as a non-profit, we can apply for grants to expand services. Many grant organizations request we provide demographic information about the patients we serve. Your privacy is important to us, we do not share your personal information or identity with third parties or advertising agents.

Name * Mailing Address * County * Date of Birth * Age SSN * Primary Phone # * Alternate Phn # E-Mail Address I do NOT want to be contacted by email for: Current Student? * Please indicate if child is: Gender * Gender Identity * Sexual Orientation * Race: Is your Primary Language English? * Preferred Language: Father's Info * Father's Employer Father's Insurance Mother's Info * Mother's Employer Mother's Insurance Parental Costody * Other Family Size * Annual Family Income *

Responsible Party/Employer Information/Insurance Carrier

Person Responsible for Bill * Address Phone # Employer Employer Phone # Method of Payment: * Primary Medical Insurance * Policy Number Group Number Secondary Medical Insurance Policy Number Group Number Dental Insurance Company Policy Number Group Number Insured's Relationship to Patient

Consent:

CONSENT FOR TREATMENT: This is to certify that I, the undersigned, consent to the administration of whatever anesthetics and the performance of whatever medical and/or dental procedures may be decided on by myself and the attending proider to be necessary or advisable, rendered via face-to-face interaction or telemedicine. I hereby voluntarily request, consent to and authorize Fordland Clinic dentists, hygienists, physicians, nurse practitioners, behavioral health clinicians or other practitioners to provide medical and surgical treatment, including but not limited to: diagnostic procedures, lab testing, and administration of medications as is deemed necessary and advisable. I further understand and acknowledge that HIV and Hepatitis testing may be performed upon me or my child without written consent, under the circumstances that a Fordland Clinic employee sustains a percutaneous mucous membrane or other exposure to my blood or other bodily fluids.

INFORMATION: I certify the information that I have given in this form is correct. Should there be any changes, I will notify the provider prior to treatment.

ASSIGNMENT OF INSURANCE BENEFITS: I request payment of authorized Medicare &/or other Insurance benefits on my behalf for any services furnished to me by Fordland Clinic, Inc. I agree to pay any collection fees in the event that my account is turned over to a collection agency for failure to pay outstanding charges for more than three months. I understand that I may be responsible for additional charges generated from abnormal lab or pathology results.

RELEASE OF INFORMATION: I also authorize Fordland Clinic, Inc. to release the minimum necessary medical &/or billing information concerning my care, including copies of my medical records, electronically or on paper, for the purpose of ongoing medical treatment and billing for services provided. I acknowledge that this authorization is valid for one year, or until all accounts are settled.

PHOTO RELEASE: I give Fordland Clinic (FC) the right to use my name, photograph, image or voice in all forms for promotion of FC or media coverage of FC and its events with no monetary compensation to myself.

HIPAA: I acknowledge that I have been notified of Fordland Clinic, Inc's HIPAA (Health Insurance Portability and Accountability Act) Notice of Privacy Practices. I have been given a chance to review them and offered a copy. I also acknowledge that if I wish to have a copy in the future, it is available to me. I understand that general e-mail is not a secure method of communication, and if I send e-mail to a provider or request a provider respond to me by e-mail, I acknowledge that I am aware that this is not secure and is not compliant with HIPAA rules & regulations.

Authorization Electronic Signature of Patient's Parent/Legal Guardian * Date * Name of Health Care Provider Name of Dental Provider

Important Change in our Appointment Policy

Fordland Clinic strives to offer high quality, affordable services to all of our patients in a timely manner. It is important that you arrive to your scheduled appointment on time or let us know as soon as possible that you are unable to keep your scheduled appointment. By notifying us that you cannot keep your appointment, we can offer that appointment to another patient who may be waiting for care. Below you will see our policy on cancellations and no-show appointments. Please ask if you have questions. *You must give at least 2 hour notice in order to cancel or reschedule any appointment. Failure to do so will result in a "no show" in your appointment history. *You may leave a message if no one is available to take your call or if you are calling after hours. *You must keep your contact information current. If we are unable to confirm your appointment due to outdated contact information, your appointment may be cancelled. ** *If you are late to your appointment, you may not be seen. *If you fail to show for 3 appointments in a 12-month period, you may lose the right to schedule appointments in the future. We will continue to see you as a patient, but you will have to walk in and wait until there is an opening in the schedule to be seen.

Electronic Signature *

Protected Health Information Policy / HIPAA

I hereby authorize release of my Protected Health Information (PHI) for discussion of my care and treatment or payment to the person(s) specified below.

Authorized to Receive PHI Authorized to Receive PHI Authorized to Receive PHI

NOTE: This form does not give the above referenced persons permission to make health care decisions for the patient. We will not release via telephone or any other means of communication to any friends or family members not listed above unless the patient has an opportunity to object and does not (documented) or if it is reasonable to infer that the patient does not object, such as when a patient brings a spouse into the room when treatment is being discussed. An exception is only made if the release is needed in emergency situations.

Preferred Method of Contact

Cell Phone Home Phone Work Phone E-Mail Contact Release Information: *

Acknowledgement of Receipt of Notice of Privacy Practices

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly or indirectly, obtain payment from third-party payors and/or conduct normal healthcare operations such as quality assessments and physician certifications. I have been offered a copy or received, read and understand your 'Notice of Privacy Practices' containing a more complete description of the uses and disclosures of my PHI. I understand that this organization has the right to change it's Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

Electronic Signature * Date *

The information on this form will remain in effect until revoked/cancelled in writing by the patient or patient representative listed above.

Permission To Treat Without Parent/Guardian Present

Permissions * Permitted to Bring my Child to Appts Permitted to Bring my Child to Appts Permitted to Bring my Child to Appts Permitted to Bring my Child to Appts This Permission form is good for: * specified date of service Electronic Signature * Date *

How Did You Hear About Our Clinic?

Referred By: