Document Acknowledgement - Cornerstone Family Healthcare

Document Acknowledgement
Patient Name: ______________________________________ Date of Birth: _____/_____/_____ Patient ID# __________
By signing each statement below I acknowledge that I have received a full version of each document. I understand that is my responsibility to read each document and
ask for clarification or more information if necessary.
Patient Initials
Assignment of Benefits:
I authorize payment of insurance benefits to Cornerstone Family Healthcare (CFH) for medical, dental and/or radiology services provided to me. I
authorize the release of medical or other information necessary to determine benefits coverage and eligibility. I understand that I am financially
responsible for charges not covered by my insurance. It is my responsibility to notify GHVFHC of any changes to my health care coverage.
Notice of Privacy Practices & HIPAA Acknowledgement:
CFH is committed to protecting your Personal Health Information (PHI) and stay in compliance with federal and state laws such as HIPAA. I have
received a copy of the Notice of Privacy Practices and understand how my PHI may be used, as well as my rights and CFH’s rights regarding PHI.
E-Prescribing Consent:
I give consent to CFH to enroll me in the E-Prescribe Program. This includes sending prescriptions electronically to the pharmacy of my choice, as well
as requesting and using prescription medication history from other healthcare providers and pharmacy benefit payers and databases.
Consent to Photograph for Electronic Health Records:
I give consent to CFH to take my photograph to be stored in my electronic health record. This photograph will be used to identify me and help protect
me against identity theft.
Patient Bill of Rights and Patient Rights & Responsibilities:
I have received the Patient Bill of Rights and Patient Rights & Responsibilities document. General BOR:____ Mental Health Services BOR:____
Advanced Directives:
I have received the information on Advanced Directives. I understand that in order for my Advanced Directives to be honored, I must complete and
submit a Health Care Proxy and/or Living Will form that has been provided to me.
General:_____ Mental Health Services : _____
Consent to Release Medical/Dental Information:
I hereby give consent to the following individuals to have access and obtain copies of my medical/dental information. This includes health history,
exam information, tests and lab results. Information will be provided, based on my consent below.
Name: ____________________________________________Phone #: ______________ Relationship to me: __________________________
This individual may have access to my:
 Medical/Dental Information  HIV Status/Information  Mental Health Information  State Reportable Results
I would like to receive text messages from CFH. Such text messages may include appointment reminders, preventative/diagnosis related care
reminders and diagnosis related health education material. This excludes information related to HIV, Substance Abuse & Mental Health.
Initial to OPT IN for text messaging
Witness: Name of CFH Employee: _____________________________
Patient Signature: ______________________________
Date:_____/_____/_____
Revised 5/17/2016
Page 1 of 1
GENERAL MEDICAL & DENTAL CONSENT FOR TREATMENT
Patient Name: ____________________________ Date of Birth: ___/___/___
Patient ID#___________
1. I am asking for medical care and treatment at Cornerstone Family Healthcare and agree to accept
services which may diagnose a medical condition, procedures to treat my condition and routine
dental and medical care. I understand that these services will be provided to me by physician,
dentist, nurse practitioner, midwives, physician assistant and other health care providers, some of
whom may be in training. I have not been given any guarantees as to the results of the services I will
receive.
2. I understand that my agreement to accept these services will remain in effect unless I say that I no
longer want these services or until my treatment is completed.
3. I understand that my agreement to accept these services is called a General Consent and that it
includes any routine procedures(s) or treatment(s) such as blood drawing, physical examination,
administration of medication(s), taking x-rays, use of local anesthesia and other non-invasive
procedures.
_____________________________________________________
Signature of Patient or Parent/Legal Guardian of Minor Patient
______________
Date
If the patient cannot consent for him/herself, the signature of either the health care agent or legal guardian
who is acting on behalf of the patient, or the patients next of kin who is agreeing to the treatment for the
patient, must be obtained.
____________________________________________________
Signature of Health Care Agent/Court Appointed Guardian
______________
Date
____________________________________________________
Signature & Relation of Next of Kin
______________
Date
Witness:
I,____________________________ am an employee of Cornerstone Family Healthcare who is not the
patient’s health care provider and I have witnessed the patient or other appropriate person voluntarily signs
this form.
Signature and title of Witness ________________________________________________
Interpreter/Translator: To the best of my knowledge the patient understood what was
interpreted/translated and voluntarily signed this form.
Signature of Interpreter/Translator______________________________________________
Revised 5/17/2016
Page 1 of 1
HealthlinkNY Health Information Exchange
LEVEL ONE HEALTH INFORMATION EXCHANGE CONSENT FORM
ORGANIZATION:
Cornerstone Family Healthcare
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deciding whether to give you health insurance or pay your bills.
Please carefully read the Consent Form Information Sheet about how your information is used before
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NEW PATIENT REGISTRATION FORM (revised 05/17/2016)
PATIENT ID NUMBER
_____________
PATIENT INFORMATION
Patient’s Legal last name:
Legal first name:
Today’s Date:
Middle:
Preferred name:
Social Security Number:
DOB:
Mailing Address (if different from home address)
Home address:
City:
State:
E-Mail Address for Patient Portal:
Zip Code:
*Must be 18 years of age or older*
Cell phone number:
Language Needs (Collected as a federal requirement):
 Check if you prefer to
communicate in a language
other than English.
Indicate language preference
(including American Sign LanguageASL): _______________________
Veteran Status (Collected as a
federal requirement)
Home phone number:
Are you a veteran of the U.S.
military?  yes  No
Work phone number:
INSURANCE INFORMATION
*If you don’t have insurance, please ask one of our staff members how you can apply for a sliding fee discount based on your income.*
 I am insured (please provide a copy of your insurance card to the patient service representative)
❶ Primary Insurance Name: _________________________________________
Who is the primary subscriber?
 patient/myself
ID#: ________________________________________
other- Name: _____________________________________________
If other, insured date of birth: ______________________________ Insured relationship to patient ___________________________________
❷ Secondary Insurance Name (if applicable): _______________________________________ ID#: ___________________________________
Who is the primary subscriber?
other- Name: ______________________________________________
 patient/myself
If other, insured date of birth: ______________________________ Insured relationship to patient ___________________________________
❸ Name of person who is financially responsible for healthcare payments (deductibles/co-pay’s, etc.):
Myself
Other (please provide name) __________________________________________________________________________
HOW DID YOU HEAR ABOUT US?
 Internet
 Radio
 Insurance Company
 Newspaper/Magazine Ad
 Social Media
 Referral from a friend/family member
 Referral from my healthcare provider: Name and address of provider: ___________________________________________________________
 this provider is also my Primary Care Provider
If provider above is not your primary care provider, please list primary care provider here: _____________________________________________
_______________________________________________________________________________________________________________________
SIGNATURE
I certify that the above information is true and correct to the best of my ability.
Name of person completing this form:
(print)
____________________________________________________________________
Signature ____________________________________________________________________
Relationship to patient:  self
 parent
 legal guardian
 other: _______________________________________________________
NEW PATIENT REGISTRATION FORM (revised 05/17/2016)
PATIENT ID NUMBER
_____________
GETTING TO KNOW YOU
We require the following information for the purposes of understanding our population better and to satisfy our reporting requirements to the
federal government. The options for these questions were provided by those organizations which analyze this information, and in no way impact
the care you receive. Please help us serve you better by selecting the best answer to these questions. Thank you.
 Male
 Female
Race (Collected as a federal requirement):
Sex assigned at birth (Select one)
You may select one or more
Marital status (select one):  Single  Married  Partnered/Other
 White/
Caucasian
 Black or African
American
 American
 Other Pacific
Indian/
Islander
Alaskan Native
 Asian
 Native
Hawaiian
 I Decline to
provide this
information
(Collected as a federal requirement)
Sexual Orientation (Select one)
 Lesbian, gay or homosexual
 Male
 Straight or heterosexual
 Female
 Bisexual
 Transgender Male/Female to Male
 Something else/Other
 Transgender Female/Male to
female
 Don’t know
 Gender Queer
 Choose not to disclose
 Other
Ethnicity (Collected as a federal requirement): Please select one
 Non-Hispanic
 Hispanic
Gender Identity (Select one)
 I Decline to provide this information
 Choose not to disclose
Employment Status (Only for patients 18 years and older; Collected to assess potential exposures to health risks):
 Employed full-time
 Employed part-time
Occupation: _____________________________________________
 retired
 disabled
 student
 other
 I decline to provide this information
Income: (Collected as a federal requirement to examine the percentage of poverty levels within our patient population)
Anticipated annual household income for this year:
Total # of people living in household, including yourself:
Housing Status: (Collected as a federal requirement)
 I live in my own apartment/home, which is my permanent residence
 I permanently joined households with someone/another family (stable, permanent residence such as foster care, group home, or halfway
house/ living long-term with extended family members)
 I temporarily joined households with someone /another family (not a stable residence/ not permanent/ may be at risk of losing nighttime residence/ not paying rent)-Doubling-up
 I stay with different people in their homes and move around often from one house to another-Transitional
 I live in a shelter
 I live in a hotel/motel
 I live in transitional housing (room or apartment in a residence with support services)
 I live either on the street/car/park/tent/abandoned building
Pharmacy Information: Name:
Telephone number:
EMERGENCY CONTACT INFORMATION
In the event we are unable to reach you to discuss important test results, or should there be a medical emergency during one of your visits,
Cornerstone Family Healthcare will contact the person you indicate below.
Name: ________________________________________________________________
Emergency contact telephone number: Select type of phone:
 cell phone
Relationship to patient: _________________________
 home phone
work phone
Print phone number: _____________________________________ extension if applicable ______
***Please note that the person you designated above does not have the right to your (or your child’s) protected health information. If you
choose to designate this person as someone who we may discuss your (or your child’s) information with, please complete the appropriate section in the Document Acknowledgement form***