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.
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
Alaskan Native
Black
Native Hawaiian
American Indian
White
More than one race
Unknown
Other
(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
Intepreter name:
Intepreter Phone Number:
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:
How Did You Hear About People's Center Health Services?
I hereby assign, transfer, and send over to People's Center Health Services all of my rights, title, and interests to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until I give written notice revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance.
I hereby authorize treatment deemed necessary by my primary care provider at People's Center Health Service. I authorize the release of my medical records to physicians to which i may be referred.This authorization shall remain valid until I give written notice revoking said authorization.
The information on this page is correct to the best of my knowledge.
|
|
|
PATIENT OR PARENT/GUARDIAN SIGNATURE |
|
DATE & IP ADDRESS |
This is to acknowledge receipt or offering of a copy of PEOPLE'S CENTER HEALTH SERVICES.
Notice of Privacy Practice with an effective date of 01/01/2012.
|
|
|
Individual's (or Legal Representative's) Signature |
|
DATE & IP ADDRESS |
*Maybe requested to provide verification of representative status.
We made the following efforts to obtain written acknowledgement of receipt of the Notice of Privacy Practices:
However, acknowledgement could not be obtained because:
Discounted fees are available for individuals or families whose household income falls within o% and 200% of the federal poverty guidelines. If you are interested in applying for discounted services, you will need to provide information about your family and your income so your eligibility can be determined.
Family Size (includes all family members living within the household):
In order to qualify for PCHS' Sliding Fee Discount Program, you need to bring at least one document from the following list. The proof of income must be returned within 30 days of application. If you do not provide your proof of income by the due date, you will have to pay full price for services. The Sliding Fee Discount Program begins on the date your proof of income is received at the clinic. If you do not have any of this documentation, PCHS staff can assist you with self-declaring your income.
|
Income Validation Document |
Income Amount |
Copies Provided |
Employment Wages and Earnings |
Paystub from work (last 30 days) |
|
|
Self-Employed wage documentation(for last 3 months) |
|
|
Most current Tax Return |
|
|
Workers Compensation Statement/Stub |
|
|
Military leave and earnings Statement/Stub |
|
|
Employer income statement letter |
|
|
Patient income statement letter |
|
|
Benefits |
Disablility Income Statement/Stub |
|
|
Current Social Security Statement/Stub |
|
|
Unemployment Statement/Stub |
|
|
Other Income |
Statement of chid support |
|
|
Most Current Retirement Benefit Statement |
|
|
Most Current Bank Statement |
|
|
Other: |
|
|
|
Total |
|
|
|
|
|
Signature |
|
DATE & IP ADDRESS |
Yes
No
Yes
No
Yes
No
AUTHORIZATION AND RELEASE
I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION TO THE BEST OF MY KNOWLEDGE. THE ABOVE QUESTIONS HAVE BEEN ACCURATELY ANSWERED. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I AUTHORIZE THE DENTIST TO RELEASE ANY INFORMATION INCLUDING DIAGNOSIS AND THE RECORDS OF ANY TREATMENT OR EXAMINATION RENDERED TO ME OR MY CHILD DURING THE PERIOD OF SUCH DENTAL CARE TO THIRD PARTY PAYORS AND/OR HEALTH PRACTITIONERS. I AUTHORIZE AND REQUEST MY INSURANCE COMPANY TO PAY DIRECTLY TO THE DENTIST OR DENTAL GROUP INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I UNDERSTAND THAT MY DENTAL INSURANCE CARRIER MAY PAY LESS THAN THE ACTUAL BILL FOR SERVICES. I AGREE TO BE RESPONSIBLE FOR PAYMENT TO ALL SERVICES RENDERED ON MY BEHALF OR MY DEPENDENTS.
|
|
|
SIGNATURE OF PATIENT OR PARENT/GUARDIAN IF MINOR: |
|
DATE & IP ADDRESS |
|
|
|
DOCTOR'S Signature |
|
DATE & IP ADDRESS |
Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your body. Health problems that you may have, or medication that you may be taking, could have an important inter-relationship with the care you will receive. Thank you for answering the following questions.
Do you have or have you had and of the following? Please circle if YES
To the best of my knowledge, the questions on this form have been acurately answered. I understand that providing incorrect information can be dangerous to my (or my patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
|
|
|
SIGNATURE OF PATIENT, PARENT OR GUARDIAN: |
|
DATE & IP ADDRESS |