Please list ALL medications you are CURRENTLY TAKING
Please list all food, medication, and environmental allergies
I for myself do voluntarily consent to medical care, diagnostic procedures, behavioral health counseling, pharmacy or nutritional counseling services that may be done, requested or directed by or delegated in the judgment of the attending provider. I understand that I may refuse any services at any time.
I authorize release of information to all third-party payors or health and social service agencies.
I authorize release of information to Medicare and authorize Community Health and Wellness Partners of Logan County to bill my charges to Medicare.
I understand that I am still responsible for my bill even though I may have health insurance.
I understand that I will be asked to provide proof of income at least once each year, so my charges can be accurately calculated for the sliding fee schedule.
I understand that I must present a current public aid card, health insurance, or Medicare card at each visit to Community Health and Wellness Partners of Logan County when my charges are covered.
I hereby assign, transfer and set over to Community Health and Wellness Partners of Logan County all of my rights, title and interest to my medical reimbursement benefits under my insurance policies. Community Health and Wellness Partners is required by law to protect the privacy of its patients. It will keep confidential any and all patient healthcare information.
This notice is in compliance with the guidelines set forth in the Health Insurance Portability and Accountability Act. (HIPAA) of 1996, effective April 14th, 2003.
By typing my name below as my signature I consent to submit this information to Community Health & Wellness Partners. I may be contacted by an employee of CHWP to validate my identity. I am not required to sign this form in order to submit it, but will be asked to sign a paper copy of it prior to receiving services.
Acknowledgement of receipt of Notice of Privacy Practice regarding protected health Information:
I have received the Practice’s Notice of Privacy. Photocopies of this document are to be as valid as the original. Fundraising & Marketing: Unless you request us not to, we will use your name and address to support our fund-raising or marketing efforts. If you do not want to participate in fund-raising or marketing efforts, please check off the following box.
Please exclude me from any Fundraising Marketing
Assignment of Benefits:
I acknowledge financial responsibility for all facility and physician fees. I understand that the physician billing office will file my insurance claim and I assign direct payment to the physician all payments made under the terms and provisions of my policy. I further understand that any disputes on coverage are between my insurance carrier and myself and I will be responsible for payment for denied services regardless of the outcome of my dispute. I acknowledge financial responsibility for all charges if inaccurate insurance information is given at time of service and the information is not corrected prior to my insurance company’s timely filing limit.
Medical Records Exchange:
CHWPLC participates in one or more Health Information Exchanges (HIE). HIEs are electronic networks that securely provide and retrieve access to your health records for a better picture of your health needs. CHWPLC Providers, as well as other healthcare providers, may provide and retrieve access to your health information through an HIE for treatment, payment or other healthcare operations. As a CHWPLC patient, you have the ability to opt out of any HIE at any time by notifying a CHWPLC Associate. This is a voluntary agreement. Unless you advise us differently, your information may be accessed through an HIE by your CHWPLC provider.
I understand that performing a medication reconciliation in order to prevent adverse drug interactions and overdose is a critical component to my care. By initialing this section, I authorize my provider to query and review my medication fill history including drug, dose, form, strength, prescribing provider, and pharmacy.
Communication Preferences Regarding PHI
To assist in your care, it may be necessary to release our Protected Health Information to someone other than yourself. To whom may we talk? Please Check boxes and write in name(s).
May we leave a message on: home mobile work
Preferred method for appointment remind: Check all that apply
Call to home Call to mobile Text to mobile
Before approval can be given, the following MUST be received at time of or within 30 days of application.
List yourself on Line 1, spouse or significant other on Line 2, and all dependents under the age of 19 on Lines 3-6
Office Use Only
Certification: I certify that the household size and income information shown above is correct. I understand that documentation supporting my household financial position is required before my discount can be approved and that I must provide this information within 30 days or prior to my next visit if sooner.
I understand that I must update this information if my situation changes and that a new Sliding Fee Application must be completed at least every twelve (12) months. I have received information explaining the program and I understand and agree to abide by the terms. I understand that if I am eligible for the sliding fee discount; I will be responsible to pay at least a minimum nominal fee for healthcare services. If an unpaid balance exists on my account after applying my sliding fee discount, I agree to make payment arrangements and honor the terms. I understand that if I am unable to make a payment in any given month, I must contact the Billing Office prior to the due date to discuss my need to modify my payment arrangement.
DO NOT sign below if you wish to be considered for a discount. Signing below will void your Sliding Fee Application. Even if you have insurance, you may still qualify for an additional discount if you provide your household income information and provide applicable documentation as stated on the application.
I choose not to complete the Sliding Scale Application at this time. I am waiving my right to any discount to which I may otherwise be entitled. I understand that I will be responsible for full payment of all charges at the time of service.
To see if you qualify, review the following information... Find your household size and monthly income on the chart
Step 1. Circle Household Size
Step 2. Circle MONTHLY Gross Income Range (on same line) for household size you selected
Step 3. If your circle is in the middle two columns you qualify for a sliding fee discount **
*Nominal Fee May Apply/p>
**Final rate to be determined by submitted documentation, CHWPLC staff and current sliding fee scale