Patient Sign-in

Patient Registration Form

Patient Registration( * mandatory to fill )

How do we contact you?( * mandatory to fill )

Please select below

Are you a student?
Yes No
Do you have an Interpreter?
Yes No
Do you have insurance?
Yes No

Employer Information

Please circle your answers below and check the income level (for funding reports only; no names are disclosed):

African Born
African American
Asian/Pacific Islander
Hispanic
Native American
Caucasian
Other

Who do we contact in case of an emergency?( * mandatory to fill )

Primary Insurance Information( * mandatory to fill )

Responsible Party (Person responsible for paying the bill)( * mandatory to fill )

SELF OTHER

Do you have a Living Will or Advance Directive?
Yes
No
I HEREBY AUTHORIZE SERVICES RENDERED TO ME BY PEOPLE’S CENTER AND AGREE TO PAY FOR SUCH SERVICES INCLUDING THOSE SERVICES CONSIDERED NON-COVERED OR DENIED BY MY INSURANCE COMPANY.
ASSIGNMENT OF BENEFITS -- I hereby authorize payment of the amount due to me in my pending insurance claim be made directly to People’s Center. Payment is authorized upon your receipt of an itemized statement of services.
PRESCRIPTION HISTORY RELEASE -- I hereby authorize People’s Center to view my prescription history when providing evaluation or treatment services to me.
RECORDS RELEASE -- I hereby authorize the exchange / release of any information, via paper or electronic review by People’s Center with any providers, hospitals and / or specialist(s) to whom I may receive care from, be referred for care, or to my insurance company to determine benefits and secure payment for services provided.
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

HEALTH DATA EXCHANGE (initial YES or NO)

Yes, I authorize my insurer, health plan, or claims administrator and provider to share with each other my health information for care coordination and quality improvement purposes. This includes sharing my health information from treatment I have received at health care providers not related to People’s Center. My insurer, health plan or claims administrator may also share the above information with a care system or accountable care organization in which People’s Center participates. If I do not want my health information shared for these purposes, I may opt out by initialing the statement below. No, I do not authorize my insurer, health plan, or claims administrator and provider to share my health information as described above.
NOTICE OF PRIVACY PRACTICES - I acknowledge that I was given/offered the Notice of Privacy Practices today, OR at a previous visit.
(Please click below to draw/upload sign)
(Your IP Address : )

How Did You Hear About People’s Center Health Services?
For Office Use Only:

Chart/MRN#__________________________________________________

Primary Care Provider___________________________________________

Thank you for visiting People's Center Health Services. We want your visit to be pleasant and comfortable. Please help us by completing this form.
Patient Information

Personal Details

Appointment date:
First Name: Last Name: Date Of Birth: Social Security Number: Gender: Marital Status:

Address

Address: City: State: Zip Code: Home Phone: Cell / Alternative Phone: Driver's License No: State:

Emergency Contact Information

Name: Relation: Home Phone:

Professional Information

Employer: Work Phone: Employer's Address:

Please circle your answers below and check the income level (for funding reports only; no names are disclosed):

African Born African American Asian/Pacific Islander Hispanic Native American Caucasian Other

Details

(includes all family members living within the household)
$0 - $25,000 $25,100 - $50,000 $50,100 - $75,000 $75,100 - $100,000 Over $100,000
Yes No
School name:
Yes No
Intepreter name: Intepreter Phone Number:
Yes No

Insurance Information

Insurance Company Name: Insurance Company Address: Group Number from card: Insured ID#:

Responsible Person for Account

Name: Relation Date of Birth: Address: City: State: Zip Code:
Do you have a Living Will or Advance Directive? Yes No
Date of Living Will or Advance Directive:

I HEREBY AUTHORIZE SERVICES RENDERED TO ME BY PEOPLE’S CENTER AND AGREE TO PAY FOR SUCH SERVICES INCLUDING THOSE SERVICES CONSIDERED NON-COVERED OR DENIED BY MY INSURANCE COMPANY.

ASSIGNMENT OF BENEFITS -- I hereby authorize payment of the amount due to me in my pending insurance claim be made directly to People’s Center. Payment is authorized upon your receipt of an itemized statement of services.

PRESCRIPTION HISTORY RELEASE -- I hereby authorize People’s Center to view my prescription history when providing evaluation or treatment services to me.

RECORDS RELEASE -- I hereby authorize the exchange / release of any information, via paper or electronic review by People’s Center with any providers, hospitals and / or specialist(s) to whom I may receive care from, be referred for care, or to my insurance company to determine benefits and secure payment for services provided.

The information on this page is correct to the best of my knowledge.

 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

HEALTH DATA EXCHANGE (INITIAL YES OR NO)

Yes, I authorize my insurer, health plan, or claims administrator and provider to share with each other my health information for care coordination and quality improvement purposes. This includes sharing my health information from treatment I have received at health care providers not related to People’s Center. My insurer, health plan or claims administrator may also share the above information with a care system or accountable care organization in which People’s Center participates. If I do not want my health information shared for these purposes, I may opt out by initialing the statement below.

No, I do not authorize my insurer, health plan, or claims administrator and provider to share my health information as described above.

NOTICE OF PRIVACY PRACTICES - I acknowledge that I was given/offered the Notice of Privacy Practices today, OR at a previous visit.
 
 
Patient/Guardian Signature DATE & IP ADDRESS

How Did You Hear About People's Center Health Services?

Details Of Organization

Details

  
 
Signature DATE & IP ADDRESS
For Office Use Only:

Chart/MRN#__________________________________________________

Primary Care Provider___________________________________________

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