Patient Application - Good Shepherd Community Clinic, Inc.

The Good Shepherd Community Clinic, Inc.
20 12th Ave., NW, Ardmore, OK 73401
580-223-3411 ~ www.gsccardmore.com
NEW PATIENT INFORMATION
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
To be seen in the clinic, you must call by noon the business day before your appointment and
confirm your appointment (i.e., call on Thursday for a Monday appointment). If you do not call
to confirm your appointment, you may lose your appointment slot to someone else.
Always bring all medications you are taking to your appointment. This includes over-thecounter medications. Bring the empty bottle, should you run out.
All prescriptions will be written to last until your next appointment. Check your prescription
while you are with your healthcare provider to ensure there are enough refills. Please do not
call or ask for additional prescriptions prior to your next appointment.
Sample medications are offered to GSCC patients dependent upon availability. Samples are
donated to the clinic, and are not always available.
For medication refills, please call your pharmacy and ask them to FAX us (580-226-6213). Do
not call GSCC if you need a refill. If you have not been seen by one of our healthcare providers
within a 3 month period and you desire a refill, you must schedule an appointment with GSCC
before any prescription will be written.
Medical treatment and/or prescriptions cannot be administered over the phone; in order to
receive medical treatment or medication, you must make an appointment to be seen by one of
our healthcare providers.
Policies concerning lab work: You will NOT be notified about normal lab results. No
information will be given over the telephone. We will not mail or fax information to you. You
may pick up a copy of your labs at the office during your appointment. If lab results are
abnormal, follow-up appointments will be made so that you may discuss with results with your
physician.
Phone calls: Please leave only ONE message. The clinic staff will return your telephone call
within 24 hours. Any medical concerns will be directed to the healthcare providers and you will
receive a follow-up call from our staff.
Please alert us within 30 days of any change in your name, address, phone number, income, or
health insurance coverage.
GSCC is unable to treat chronic pain management and will be unable to prescribe narcotic
medications.
GSCC staff is responsible for making all referral appointments, when necessary. All calls
regarding referrals must go through GSCC staff.
The Good Shepherd Community Clinic, Inc.
20 12th Ave. NW, Ardmore, OK 73401
580-223-3411 ~ www.gsccardmore.com
Applicant Name: ____________________________________________
Date: ______________________
(Please Print)
Services Requested:
_____ Medical (based on sliding fee schedule)
_____ Dental (based on sliding fee schedule, fee must be paid when appointment is scheduled)
_____ Optical (cost is $65.00 for frames & lenses, fee must be paid when appointment is scheduled)
Eligible applicants must:
 Be uninsured (no health coverage of any kind)
 Be at 200% of the Federal poverty level or below
 Live in one of the following counties: Carter, Johnston, Love, Marshall or Murray
Please include the following information with your application. Bring 1 copy of each document.
Only completed applications with copies of the required documents will be processed.
_____
_____
_____
_____


_____







_____
_____
_____
_____
Copy of Social Security card (if available) for each applicant
Copy of picture identification for each applicant
Proof of residency (copy of utility bill)
Proof of earned income:
If you are employed:
o Current tax return
o 1 month of recent consecutive paystubs for applicant, or if paid by cash, a letter from employer on
company letterhead stating rate of pay per hour and number of hours per week worked for the past
month for applicant.
If you are self-employed:
o Please list all gross earnings for the last 3 consecutive months and itemize all work expenses for those
same months.
Proof of unearned income, if applicable (must provide two of the following):
Food stamps acceptance letter (must be a letter from DHS)
Child Support (must be a letter from Child Support Services)
Social Security Income (must be a letter from Social Security Administration)
Unemployment Benefits (must be a letter from Unemployment department)
Worker’s Compensation Benefits (must be a letter from Worker’s Compensation)
Housing assistance letter (must be a letter from DHS, Section 8, etc.)
Letter of support from family, friends, etc. (must be notarized)
Proof of income from anyone living with you in the household
Copy of 2 most recent, consecutive checking and/or savings account statements
Medicaid denial letter (if applicable)
Letter from employer stating if health insurance is offered for employee and / or family, when open
Enrollment starts, and if health insurance is taken, when would coverage take effect?
You must have ALL paperwork completed prior to being seen at the clinic.
PATIENT AGREEMENT FOR THE GOOD SHEPHERD COMMUNITY CLINIC, INC.
The Good Shepherd Community Clinic, Inc. is a non-governmental, non-profit agency designed to provide health care to
adults who have no other means of health care.
To better serve you, we ask for your cooperation in following the policies listed below: If you are unable to follow these
guidelines, or if you find them unacceptable, another healthcare provider may be better able to meet your needs.
I UNDERSTAND AND AGREE TO THE FOLLOWING:
Please initial each item.
_____ 1. I will inform GSCC if my address, telephone number(s), income or insurance status changes within 30 days of
the occurrence.
_____ 2. I will call GSCC to confirm my appointment by noon the day before my scheduled appointment. If I fail to call,
my appointment may be cancelled. I will have to call to reschedule for another appointment.
_____ 3. If I miss 3 appointments without notifying GSCC, I understand that I may no longer be able to receive services
at GSCC.
_____ 4. I authorize any healthcare professional associated with GSCC to disclose any personal health information to
other healthcare professionals when medically necessary.
_____ 5. I authorize the administrative staff of GSCC to disclose my registration and screening information for the
purposes of obtaining charitable healthcare at another facility.
_____ 6. I understand that I am solely responsible for following through with testing and treatment orders and
referrals mandated by healthcare providers at GSCC. I understand that if a referral is made, I am responsible for
keeping each appointment. If I miss a referral appointment, I understand that my privileges to be seen may be
suspended. I understand that if I fail to follow directions or orders from the healthcare providers, my treatment
may be unsuccessful.
_____ 7. I understand that if I am uncooperative, verbally or physically abusive, intoxicated, or behave in a manner
deemed inappropriate by the GSCC staff, I will not be eligible for current or future services at GSCC.
_____ 8. I understand I am receiving medical, dental, or optical services provided by healthcare professionals through
a charitable organization. By signing below, I am stating that I release all healthcare professionals from any and
all civil liability relating in any way to any act or omission that results in death, damage or injury to me.
_____ 9. I understand that GSCC does not prescribe any narcotic medications.
I have received a full explanation of GSCC’s services, and I understand and agree to all of the above
statements. I understand that I can be terminated from the clinic if I have provided wrong or misleading
information, or if I fail to follow the policies listed above.
I have read and understand the above information.
Patient’s Name (Printed): ___________________________________________
Patient’s Signature: ________________________________________________
Date: __________________
Witness’s Signature: _______________________________________________
Date: __________________
GOOD SHEPHERD COMMUNITY CLINIC, INC.
20 12th Ave., NW, Ardmore, OK 73401
580-223-3411 ~ www.gsccardmore.com
Consent for Treatment
I hereby authorize The Good Shepherd Community Clinic, Inc. to use and /or disclose my health information which specifically
identifies me or which can reasonably be used to identify me to carry out my medical, vision, and / or dental treatment. I
understand that while my consent is voluntary, if I refuse to sign this consent, the healthcare providers of The Good Shepherd
Community Clinic, Inc. may refuse to treat me. I authorize the physicians, nurse practitioners, and/or dentists to administer such
treatment as they deem advisable for my diagnosis and treatment. I certify that I have been made aware of the role and services
offered by the physician, nurse practitioner or dentist and I consent to care by such providers. I understand that these services are
voluntary and that I have the right to refuse these services. This consent will remain in full force unless revoked in writing and will
not affect any actions that were taken prior to receiving my revocation. A photocopy of this consent shall be considered valid as
original. I personally assume full responsibility for the risks and consequences that may occur by reason of this care and treatment
and I hereby release and relinquish any and all claims against The Good Shepherd Community Clinic, Inc. or anyone acting on its
behalf for any injury or damage that I may sustain in the course of this care and treatment; this may include up to, but not limited to
personal injury, property damage, direct or consequential.
Patient Signature: ___________________________________________________
Date: ______________________
Authorization to Release or Obtain / Receive Healthcare Information
Individual Information (Please Print):
Patient’s Name: __________________________________________
Date of Birth: _________________________
Previous Name (if applicable): _______________________________
Social Security #: ______________________
Address: ________________________________________________
City: ________________________________
State: _____________________
Telephone #: _________________________
Zip: ________________
Scope and Purpose for sharing or to obtain / receive patient information
The purpose of this authorization is to allow The Good Shepherd Community Clinic, Inc. the ability to share my protected health information and/or
to obtain/receive my protected health information from any of the entities listed below.
Authorization to share or to obtain information
I authorize The Good Shepherd Community Clinic, Inc. as set forth below, to share and/or obtain/receive my protected health information for
reasons in addition to those already permitted by law. This form will remain in effect for the time period that I am a patient of The Good Shepherd
Community Clinic, Inc.
What information may we release?
_____ All PHI (Personal Health Information)
_____ Office notes
_____ Lab / Diagnostic test results
_____ Appointment information
_____
_____
_____
_____
Billing Information
Psychotherapy / Mental Health
Prescription
Other: _____________________________________________________
I authorize the actions, persons/organizations listed below to share, obtain, or receive my protected health information:
*All Referral Physicians
*Healthcare Providers
*Medical referral of patient to another healthcare facility
*Mental Health Services of Southern Oklahoma
*Mental Health Facility
*Mental Health Counseling Services
*Dental Facility / Providers
Patient signature: ___________________________________________
Date: ______________________
Date: ________________
HEALTH HISTORY QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Name
 M
(Last, First, M.I.):
 F
DOB:
Social Security Number:
Street Address:
PO Box (mailing only):
City, State, Zip :
Home Phone:
Cell Phone:
Work Phone:
Language:
Housing:
Need Interpreter?
OWN
RENT
COMMUNITY SHELTER
YES
STAYING WITH FAMILY / FRIENDS
NO
HOMELESS
Number of persons living in the household: _____________
Lived in Carter, Johnston, Love, Marshall or Murray County for:
Marital status:
 Single
 Partnered
Previous or referring doctor:
 Married
________YRS __________Months
 Separated
 Divorced
 Widowed
Date of last physical exam:
Date of last eye exam:
Surgeries
Year
Reason
Hospital
Other hospitalizations
Year
Reason
Have you ever had a blood transfusion?
Hospital
 Yes

No
List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
Name the Drug
Strength
Frequency Taken
Allergies to medications
Name the Drug
Reaction You Had
HEALTH HABITS AND PERSONAL SAFETY
ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.
Exercise
 Sedentary (No exercise)
 Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
 Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
 Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes)
Diet
Are you dieting?
 Yes

No
If yes, are you on a physician prescribed medical diet?
 Yes

No
 Yes

No
Are you concerned about the amount you drink?
 Yes

No
Have you considered stopping?
 Yes

No
Have you ever experienced blackouts?
 Yes

No
Are you prone to “binge” drinking?
 Yes

No
Do you drive after drinking?
 Yes

No
Do you use tobacco?
 Yes

No
# of meals you eat in an average day?
Caffeine
Rank salt intake
 Hi
 Med
 Low
Rank fat intake
 Hi
 Med
 Low
 None
 Coffee
 Tea
 Cola
# of cups/cans per day?
Alcohol
Do you drink alcohol?
If yes, what kind?
How many drinks per week?
Tobacco
 Cigarettes – pks./day
 # of years
Drugs
 Chew - #/day
 Pipe - #/day
 Cigars - #/day
 Or year quit
Do you currently use recreational or street drugs?
 Yes

No
Sex
Have you ever given yourself street drugs with a needle?
 Yes

No
Are you sexually active?
 Yes

No
If yes, are you trying for a pregnancy?
 Yes

No
 Yes

No
Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health
problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you
 Yes
like to speak with your provider about your risk of this illness?

No
If not trying for a pregnancy list contraceptive or barrier method used:
Any discomfort with intercourse?
FAMILY HEALTH HISTORY
AGE
SIGNIFICANT HEALTH PROBLEMS
AGE
Children
Father
Mother
Sibling












M
F
M
F
M
F
M
F
M
F
M
F








SIGNIFICANT HEALTH PROBLEMS
M
F
M
F
M
F
M
F
Grandmother
Maternal
Grandfather
Maternal
Grandmother
Paternal
Grandfather
Paternal
MENTAL HEALTH
Is stress a major problem for you?

Yes

No
Do you feel depressed?

Yes

No
Do you panic when stressed?

Yes

No
Do you have problems with eating or your appetite?

Yes

No
Do you cry frequently?

Yes

No
Have you ever attempted suicide?

Yes

No
Have you ever seriously thought about hurting yourself?

Yes

No
Do you have trouble sleeping?

Yes

No
Have you ever been to a counselor?

Yes

No
WOMEN ONLY
Age at onset of menstruation:
Date of last menstruation:
Period every _____ days
Heavy periods, irregularity, spotting, pain, or discharge?

Yes

No
Are you pregnant or breastfeeding?

Yes

No
Have you had a D&C, hysterectomy, or Cesarean?

Yes

No
Any urinary tract, bladder, or kidney infections within the last year?

Yes

No
Any blood in your urine?

Yes

No
Any problems with control of urination?

Yes

No
Any hot flashes or sweating at night?

Yes

No
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?

Yes

No
Experienced any recent breast tenderness, lumps, or nipple discharge?

Yes

No

Yes

No
Do you feel pain or burning with urination?

Yes

No
Any blood in your urine?

Yes

No
Do you feel burning discharge from penis?

Yes

No
Has the force of your urination decreased?

Yes

No
Have you had any kidney, bladder, or prostate infections within the last 12 months?

Yes

No
Do you have any problems emptying your bladder completely?

Yes

No
Any difficulty with erection or ejaculation?

Yes

No
Any testicle pain or swelling?

Yes

No
Date of last prostate and rectal exam?

Yes

No
Number of pregnancies _____ Number of live births _____
Date of last pap and rectal exam?
MEN ONLY
Do you usually get up to urinate during the night?
If yes, # of times _____
OTHER PROBLEMS
Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.

Skin

Chest/Heart

Recent changes in:

Head/Neck

Back

Weight

Ears

Intestinal

Energy level

Nose

Bladder

Ability to sleep

Throat

Bowel

Other pain/discomfort:

Lungs

Circulation