If yes, please specify who and their relation to you and provide a copy of document to CHWP.
What are your top 3 goals for your first appointment? Goal #1Goal #2Goal #3
Because we are partially funded by a federal grant, we are asked to collect income information. Please determine the number of persons in your household and check your annual (yearly) income range. This information is for generalized reporting regarding the health center. NO PERSONAL INFORMATION IS SHARED, but we may recommend completing our sliding fee scale application based on your response.
Please check any condition you have been diagnosed with by a medical professional/provider.
Please list all medications, vitamins, supplements that you are currently taking. Please bring medications.
Please list medication, food, health related allergies and reactions. If reaction not known, enter "unknown".
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. Signature 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. Date
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: CHWP 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. CHWP 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 CHWP patient, you have the ability to opt out of any HIE at any time by notifying a CHWP Associate. This is a voluntary agreement. Unless you advise us differently, your information may be accessed through an HIE by your CHWP provider.
Rx-History Consent: 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
Signature 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. Date
Full address (include city, state, and zip code) Patient date of birth
The Community Health & Wellness Partners sliding fee discount program provides for a reduced cost of service for patients who belong to a household that is under 200% of the Federal Poverty Level. The discount can be utilized for all services received by an eligible patient on a single date of service. The total cost could range from $25-$65 for services such as general office and behavioral health visits, procedures, preventative exams, and most vaccines. Patients can be eligible for the sliding fee discount, even if they have insurance coverage. The discount will be applied to any remaining copay, coinsurance or deductible amounts for that date of service. The chart below provides information on who may qualify:
Step 1. Find household size
Step 2. Find estimated MONTHLY gross income range (on same line) for household size you selected
Step 3. If your in a column listing slide A-E, you may qualify for a sliding fee discount
*Nominal Fee May Apply
Final rate to be determined by submitted documentation, CHWPLC staff and current sliding fee scale
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. The application will be applied to all persons who are patients of Community Health & Wellness Partners.
If you report $0 income for the household, please explain how you are surviving below. When certifying the application, I also attest that reporting $0 income for my household is true and accurate.
By typing in my name below, 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 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 setup with the Community Health & Wellness Partners Billing Office.
DO NOT type your name below unless you want to WAIVE your application. By typing my name below, I choose to void the Sliding Scale Application at this time. I am waiving my right to any discount to which I may otherwise be entitled unless I complete a new sliding fee application in the future. I understand that even if I have insurance, I may still qualify for a sliding fee discount.