• PATIENT REGISTRATION FORM

    PATIENT REGISTRATION FORM

  • PATIENT INFORMATION

  • Date of Birth*
     / /
  • Format: (000) 000-0000.
  • What type of phone number is this?
  • How would you like to receive appointment reminders?

  • RESPONSIBLE PARTY

    Who is responsible for payment for services (after insurance)?
  • Who is responsible for payment for services (after insurance)?*

  • IF YOU SELECTED "SELF", YOU DO NOT NEED TO FILL OUT THE REMAINDER OF THIS PAGE, CLICK NEXT AT THE BOTTOM OF THE SCREEN.

  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • What type of phone number is this?

  • EMERGENCY CONTACT

  • Format: (000) 000-0000.
  • What type of phone number is this?

  • DEMOGRAPHIC INFORMATION

  • Sex
  • Race
  • Ethnicity
  • What is your primary MEDICAL insurance?
  • Are you a US Veteran?
  • At any point in the past 2 years, has seasonal or migrant farm work been you or your family's main source of income?
  • What is your current housing situation?
  • Is your annual household income above the Federal Poverty Guidelines?

  • If you answered "Yes", you do NOT need to fill out the remaining questions.

    If you answered "No" or "Unsure", fill out the following questions to see if you qualify for reduced fees on your bill with Northland Health Centers.

  • Would you like to fill out a Northland Cares application to se if you qualify for reduced fees?

  • SOCIAL DETERMINANTS OF HEALTH

  • If the above statement is true, you do not need to answer the questions on this page.

  • Are you worries about losing your housing?
  • What is the highest level of school that you have finished?
  • What is your current work situation?
  • In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? (Check all that apply.)
  • Has lack of transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? (Check all that apply.)
  • How often do you see or talk to people that you care about and feel close to? (for example: talking to friends on the phone, visitng friends or family, going to church or club meetings)
  • Stress is when someone feels tense, nervous, anxious, or can't sleep at night because their mind is troubled. How stressed are you?
  • Do you feel physically and emotionally safe where you are currently living?
  • In the past year, have you been afraid of your partner or ex-partner?
  • Are there any resources we can help put you in touch with based off the above questions?

  • CONSENTS AND ACKNOWLEDGMENTS

  • FINANCIAL AGREEMENT
    I hereby give authorization for payment of insurance benefits to be made directly to Northland Health Centers for     services rendered. I understand that I am financially responsible for all charges. I certify that the information I have reported concerning my insurance coverage is correct. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits from my insurance carrier.

     

    INFORMED CONSENT AND AUTHORIZATION TO TREAT
    I understand I have the right to be told the reason for the treatment/procedure(s), the benefits or risks associated with it, and other treatment options. I also authorize Northland Health Centers to perform exams, treatments, order diagnostic tests, and provide medications that the provider deems necessary for my health.

     

    AUTHORIZATION FOR EXTERNAL SERVICES AND COORDINATION OF CARE
    Northland Health Centers collaborates with external organizations for the processing of specific laboratory and radiology tests. I understand that when such services are performed by these organizations, their Patient Financial Rights and Responsibilities will apply, and I may receive billing directly from them.

    With my permission, NHC may share the minimum necessary information with my medical provider or other external healthcare providers involved in my care to support safe and coordinated treatment. I may select what information can be shared and may change or withdraw this permission at any time.

     

    PATIENT RIGHTS AND RESPONSIBILITIES
    I acknowledge and agree that I received a copy of my Patient Rights and Responsibilities. I agree that I fully understand my rights and responsibilities as a patient and that if I neglect to fulfill them, I may be terminated as a patient of NHC.

     

    HIPAA AND PRIVACY PRACTICES
    I acknowledge that I received Northland Health Centers' Notice of Privacy Practices and understand that I may ask     questions about the Notice of Privacy Practices at any time.

    My privacy is protected by federal and state laws, including HIPAA and 42 CFR Part 2.

     

    STUDENT ACKNOWLEDGMENT
    I acknowledge that Northland Health Center collaborates with universities and colleges to complete national training requirements for students to become working professionals. I understand that I may be asked if a student can participate in or observe my care while seeing a provider at NHC. I recognize that any student working with NHC patients is expected to follow NHC privacy practices, ensuring that all records, contacts, and information obtained by the student during these interactions are considered confidential and protected for patient confidentiality.

     

    RINGCENTRAL ACKNOWLEDGMENT
    I consent to receive Customer Care, Delivery Notifications, Fraud Alert Messaging, Marketing, and Public Service     Announcements SMS from Northland Health Centers using RingCentral numbers. Reply STOP to opt-out. Reply HELP for support. I acknowledge that message and data rates may apply, and messaging frequency may vary. I can go to https://shorturl.at/4LaLD for Northland's Privacy Policy and Terms and Conditions.

  • Date*
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