Please complete to the best of your knowledge. For areas ...



-403860571500Patient Registration FormPlease complete to the best of your knowledge. For areas that do not apply to the patient please enter “N/A”.Patient’s NameFirstMILastDate of Birth (DOB)MM/DD/YYSocial Security NumberMailing AddressStreet and Apartment NumberCityStateZipCountyPhysical AddressStreet and Apartment Number ?Same as MailingCityStateZipCounty1st Phone ??Cell ??Home ?????????????????????????Work??OK to Leave Message? ?Yes ?No ?????????Home2nd Phone ??Cell???????????????????????Home??????????????????????Work OK to Leave Message? ?Yes ?NoEmail Address _______________________________________________________ OK to send secure Message? ?Yes ?NoText Message (enter phone number) ________________________________________ OK to send a text message? ?Yes ?NoMarital Status: ?Single ?Married ?Separated ?Divorced????Widowed Emergency Contact NameRelationshipCell PhoneHome PhoneWork PhoneDo you have Medical or Dental Insurance? Please present your insurance card to the Medical Receptionist.Medicare ? Medicare Advantage ? Medicaid ?Other _____________________________________________________ ?No Insurance Primary Medical Insurance Plan Insured Name/Policy Owner Name Insured Date of Birth Relationship to PatientPolicy Number Secondary Medical Insurance Plan Insured Name/Policy Owner Name Insured Date of BirthRelationship to Patient Policy Number Dental Insurance Plan Insured Name/Policy Owner Name Insured Date of BirthRelationship to Patient Policy Number Parent or Guardian Name First MI LastSame as Patient Parent or Guardian Date of Birth / / Parent/Guardian Address Street City State Zip Code Parent/Guardian Employer Name Parent/Guardian Work PhoneHow did you hear about us? ? Family/Friend ? Shelter ? Health Department ? Hospital ? Social Services ? Media ? Other ____________________________Race (check all that apply)WhiteAsianAmerican Indian/Alaska NativeBlack/African AmericanNative HawaiianOther Pacific IslanderDeclined to Answer EthnicityHispanic/LatinoNon-Hispanic/LatinoDeclined to AnswerPreferred LanguageEnglishSpanishChineseArabicVietnameseOther _____________Are interpreter services needed? ?Yes ?NoSexual OrientationStraight/not Lesbian or GayLesbian or GayBisexualUnknownDeclined to AnswerWhat sex were you assigned at Birth?FemaleMaleDeclined to AnswerGender IdentityMaleFemaleTransgender Male to FemaleTransgender Female to MaleOtherDeclined to AnswerDo you live in Public Housing? ?Yes ?No Are you a Veteran? ?Yes ?No Homeless Status ? Not Homeless Street ? Doubling Up (living outdoors, encampment, car, makeshift housing) (person who is living with others; arrangement generally considered temporary and unstable) Shelter ? Transitional Housing(organized shelter) (transitioning from a homeless environment, do not include jail, institutional treatment programs, military, schools or other institutions)-60007517780?Yes ? No Migrant Farm Worker – Individual who is required to be absent from a permanent place of residence for the purpose of seeking remunerated employment in agricultural work? Yes ? No Seasonal Farm Worker – Individual who are employed in temporary farm work but do NOT move from their permanent residence to seek work; they may also have other sources of employment00?Yes ? No Migrant Farm Worker – Individual who is required to be absent from a permanent place of residence for the purpose of seeking remunerated employment in agricultural work? Yes ? No Seasonal Farm Worker – Individual who are employed in temporary farm work but do NOT move from their permanent residence to seek work; they may also have other sources of employment # of People in Household1$0 – $12,490 $12,491 - $18,735$18,736 - $24,980More than $24,981 2$0 – $16,910 $16,911 - $25,365$25,366 - $33,820More than $33,8213$0 – $21,330 $21,331 - $31,995$31,996 - $42,660More than $42,6614$0 – $25,750 $25,751 - $38,625$38,626 - $51,500More than $51,5015$0 – $30,170 $30,171 - $45,255$45,256 -$60,340More than $60,341-81280189230Please list your Pharmacy Information:Pharmacy Name: ______________________________________________________________________________________________________________________Pharmacy Address: ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________Pharmacy Telephone Number: ___________________________________________________________________________________________________________Would you like information on our Sliding Fee Discount Program? ? Yes ? No00Please list your Pharmacy Information:Pharmacy Name: ______________________________________________________________________________________________________________________Pharmacy Address: ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________Pharmacy Telephone Number: ___________________________________________________________________________________________________________Would you like information on our Sliding Fee Discount Program? ? Yes ? No6$0 – $34,590 $34,591 - $51,885$51,886 - $69,180More than $69,181-600075240665Please circle the range below indicating your estimated annual household income according to the number of people living in your home. Advance Community Health is required to report this information to the Federal government, and it helps us to better understand the needs of the communities we serve. No identifying information shall be disclosed to the federal government. Your anonymity is protected.00Please circle the range below indicating your estimated annual household income according to the number of people living in your home. Advance Community Health is required to report this information to the Federal government, and it helps us to better understand the needs of the communities we serve. No identifying information shall be disclosed to the federal government. Your anonymity is protected. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download