Community Health and Wellness Partners logo

 

New Patient Information Form

Please check the location:
 Ben Logan School Based Health Center
 West Liberty-Salem School Based Health Center



     
 
    

Insurance Information (Please present ALL Insurance Cards and Picture ID)

 
 
 
 
 
 
 

Information for Statistical Reporting Only




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?

 


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.

 
 

 


Health History

 
 

Past Medical History

Please check any condition you have been diagnosed with by a medical professional/provider.

Osteoarthritis of
Hypercholesterol ADHD
Asthma Hypertension Bipolar Disorder
Birth defects Thyroid:         Borderline Personality
Bleeding disorder:(type if known)
Gestational diabetes Schizophrenia
Cancer of
Kidney Disease Other:
COPD Liver disorder
Dementia:(type if known)
Migraine
Diabetes:     Stroke
Tuberculosis
 

Medications

Please list all medications, vitamins, supplements that you are currently taking. Please bring medications.

Medication name Dosage (mg) How often per day

Allergies

Please list medication, food, health related allergies and reactions. If reaction not known, enter "unknown".

Allergen:
Reaction:
 
 
 
 
 
 
 
 
 
 
 
 
 

 

Hospitializations

Date: Location: Reason for stay: Length of stay:
 
 
 
 
 
 
 
 
 
 
 
 


Surgical History

  Date:   Type of Surgery:   Hospital/location:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Family History
 

  Condition Mom Dad Dad's Dad Dad's Mom Mom's Mom Mom's Dad Sibling Child
  Alcoholism                
  Dementia                
  Anemia                
  Asthma                
  Birth Defects                
  Bleeding Disorder                
  Cancer
(indicate type)
 
 
 
 
 
 
 
 
  Diabetes                
  Heart Disease                
  High Colesterol                
  Stroke                
  Heart Attack                
  Migraine                
  Epilepsy                
  Glaucoma                
  Thyroid Issues                
  Suicide                
  Tuberculosis                







Social History

Have you been sexually active in the last 12 months? 
Men, women, or both: 
Have you ever had a sexually transmitted disease? Type:
Type of contraceptive/protection used:
 

 

Female History

  Date of Last Period: 
  Age at first period:
  Number of pregnancies: 
  Number of children: 
Any chance you are pregnant now? 
Complications during pregnancy?
Last PAP Smear
Where performed:
Last Mammogram
Where performed:
 

Signature of Patient (Parent/Guardian if under 18)

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.

 

Consent to Treat

 
 

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.

 

 

HIPAA

 
 
 
 

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.

 

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.

 

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).

  Yes   No  
   
   
   
   

 

Preferred method for appointment remind: Check all that apply

 
 


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.
 


 

Sliding Fee Application

 

 

GENERAL INFORMATION

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
 

Household Size Gross Household Monthly Income Less Than Gross Household Monthly Income Between Gross Household Monthly Income Greater Than
1 $1,133 $1,134-$2,266 $2,267
2 $1,526 $1,527-$3,052 $3,053
3 $1,919 $1,920-$3,838 $3,839
4 $2,313 $2,314-$4,626 $4,627
5 $2,706 $2,707-$5,412 $5,413
6 $3,099 $3,100-$6,198 $6,199
Cost Per Visit/Level Full Discount* (A) $35(B), $45(C), $55(D), $65(E) Do Not Qualify (F)
 

*Nominal Fee May Apply

Final rate to be determined by submitted documentation, CHWPLC staff and current sliding fee scale
 

Household Data Collection

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. 



Household Annual Income Estimate:
           


PATIENT AND HOUSEHOLD INFORMATION

 




 


 


Before approval can be given, the following MUST be received at time of or within 30 days of application.

  1. Current photo ID along with one proof of income for applicant and other household members over age 19.
  2. Proof of income: Copy of 2 or more checks/paystubs, Recent tax return or W-2, Public Assistance or Social Security letter, Bank Statements, Child Support, Alimony, Unemployment, Medical Assistance or Dept. of Social Services Certification letter. Include all household income)
    • Must be current within 30 days of application
    • Total Gross Income will be calculated to determine approval

 

HOUSEHOLD MEMBERS and INCOME


**** Complete this section in full unless you want to waive your right to a discount. If waiving, you may skip to the last section.****

 

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.

  Household Members   Name(s)   DOB MM/DD/YYYY   Monthly Gross Income   Employment Status
Student (S)
Employed (E)
Other (O)
  1 (self)
  2
    Dependents under age 19      
  3
  4
  5
  6

 

UPLOAD PROOF OF INCOME

If you ar unable to submit with this application a Community Health & Wellness representative will contact you after the application has been submitted.


Declaration of No Income

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.

Certification of Sliding Fee Application

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.

 

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 may be asked to sign a paper copy of it prior to receiving services.
 
Typed Name for Signature of Application Certification

Today's Date
 

 

****IF YOU SIGNED YOUR NAME ABOVE PLEASE SKIP THE NEXT SECTION AND HIT SUBMIT AT THE BOTTOM OF THE PAGE.****



Waiver of Sliding Fee Scale Discount

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.

 
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 may be asked to sign a paper copy of it prior to receiving services.

Typed Name for Signature of Waiver of Sliding Fee Application

Today's Date for Waiver of Sliding Fee Application