New Patient Form

OPTIONAL RELEASE OF INFORMATION FORM:
Please list family member or persons to whom we can release any and all of your medical information. This is entirely optional for your convenience, but may facilitate assisting you with appointments and understanding test results, etc.
Preferred Clinic

Alpine, Tx (PCHS) Marfa, Tx (MCHC) Presidio, Tx (PCMC)
Patient Name:
Date

Month Day Year
Date
Please list the family members or others person, if any whom we may inform about your general medical condition and your diagnosis (including treatment, payment and health care operations):
Name:
Relationship:
Home Phone:
Cell Phone:
Work Phone:
Name
Relationship
Home Phone:
Cell Phone:
Work Phone:
Name:
Relationship:
Home Phone:
Cell Phone:
Work Phone:
Name:
Relationship:
Home Phone:
Cell Phone
Work Phone:
Signature of Patient or Personal Representative:

Clear
Date (mm/dd/yyyy)

Month Day Year
Date
Witness:

Clear
Date (mm/dd/yyyy)

Month Day Year
Date
Relationship to Patient if not Self
Please provide patient with a copy of the “Notice of Privacy Practices” at this time.
Date:

Month Day Year
Date
Last:
First:
MI:
Gender at time of birth:
Date of Birth:
Social Security #
Mailing Address:
Physical Address:
City:
County:
State:
Zip:
Home Phone:
Cell Phone:
Email:
example@example.com
Marital Status:
Spouse's Name:
Contact Number:
Other emergency contact name:
Contact number:
Pharmacy of Choice (please check one):

City Drug Store Highland Drug Prescription Shop Other
Other Preferred Pharmacy:
INSURANCE
Front of Insurance Card
Back of Insurance Card
Primary Insurance:
Secondary:
Primary Policy Holder's Name:
Last Name:
First:
Date

Month Day Year
Date
SS#
Relationship:
UDS Federal Reporting Requirements
Name:
Date of Birth:

Month Day Year
Date
1. Number of people living in the home
2. Are You a Veteran of the United States Military? (please check one)

Yes No
3. Ethnicity (please check one):

Hispanic or Latino Non-Hispanic Unreported/Refused to Report
4. Race (please check one):

White Asian Black/African American More Than One Race Native Hawaiian Other Pacific Islander American Indian/Alaskan Native Unreported/ Refused to Report
5. Primary Language (please check one):

English Spanish Other
Other language:
6. Shelter (please check one):

Reside in own home Reside with family/friend Homeless Public Housing Shelter
7. Annual Income (please check one):

Equal to or less than $12,000 Equal to or less than: $18,000 Equal to or less than: $24,000 Equal to or less than: $30,000 Equal to or less than: $40,000 Equal to or less than: $50,000 Greater than $50,000 Prefer not to report
UDS Federal Reporting Requirements (cont):
Name:
Date of Birth

Month Day Year
Date
Identifying Migrant Patients:
1. In the last two years (or prior to retirement), have you or a member of your family, as a primary source of income, worked as an agricultural laborer, planting, tilling or harvesting crops grown on the land such as fruit and vegetables?

Yes No
If the answer is "No" please answer question 4.

If the answer is "Yes" please answer questions 2-4. This establishes them as an agricultural worker
2. Have you or a member of your family moved in the past two years to another area (establish a temporary home) in order to perform agricultural labor?

Yes No
A "Yes" to #2 qualifies them as a migrant farm worker
3. Have you or a member of your family worked in the past two years in agriculture without the need to move away from your home?

Yes No
A "yes" to #3 qualifies them as seasonal farm workers
4. Have you or a member of your family stopped traveling to work in agriculture because of disability or old age?

Yes No
A "Yes" to question #4 qualifies them as ages/disabled farm workers.
CONSENT PAGE
Authorization of Shared Information
In order to allow for the continuity of care my care, I, the responsible party, authorize Presidio County Health Services, Inc. to have two-way communications with other physicians, specialist, consultants, hospitals, diagnostic centers, pharmacies, durable medical equipment companies, and home health agencies.
Initials *

Clear
Provider Level
I, the responsible party, authorize that it is acceptable to be seen by the nurse practitioner or physician assistant when the physician is not available or per my request.
Initials *

Clear
I, the responsible party, authorize the resident, medical students, or midlevel student under the direction of this clinic to be present during my examination and treatment.
Initials *

Clear
General Consent
I, the responsible party, give permission to Presidio County Health Services, Inc. medical personnel to perform physical assessments or examination, conduct laboratory or other tests, give injections, medications, and other treatments and render other health services to the patient identified on this form. Additional consents may be required by the medical staff for additional treatment. I understand testing may include HIV/STD testing unless I, the patient, decline (opt-out screening).
Initials *

Clear
I, the responsible party, give permission to be seen by medical students and/or resident physicians who are under the supervision of PCHS clinicians.
Initials *

Clear
Patient’s Rights and Responsibilities
Presidio County Health Services, Inc. strives to offer you the highest quality health care in a courteous and timely manner. Presidio County Health Services, Inc. has provided me with a copy of “PATIENT’S RIGHTS AND RESPONSIBILITIES.” They have also encouraged me to talk openly with the people caring for me.
Initials *

Clear
Patient Acknowledgement of possible non-coverage by insurance carrier and patient responsibility (Initial): I, the responsible party, understand that my insurance carrier or third party payer may not cover my office visit or procedures, tests, and treatment. I accept that I will be responsible for paying any services I receive that may not be covered by my insurance carrier, or third party payer. I authorize this office to release to the Social Security Administration and Centers for Medicare and Medicaid Services or any other commercial insurance company, any information needed for this claim. I permit a copy of this authorization to be used in place of the original and request payment of medical benefits to this provider.
Initials *

Clear
Notice of Privacy Practices
I, the responsible party, have been provided with the information explaining the NOTICE OF PRIVACY PRACTICES. This Notice describes how health information about me may be used and disclosed and how I can get access to this information. This policy has been given to me prior to signing this consent. Please review this carefully. If you have not received the form or have any questions about our privacy policy, please do not hesitate
Initials *

Clear
Patient's name:
Date of Birth

Month Day Year
Date
Person Authorized to consent (if minor or not the patient):
Relationship to Patient:
Date of Birth of Authorized Person:

Month Day Year
Date
Signature:

Clear
Date

Month Day Year
Date
Preventative Care Health Services Inc. (dba) Presidio County Health Services, Inc.

Informed Consent for Telemedicine and/or Telehealth
Name of Patient:
Date of Birth:

Month Day Year
Date
Name of person giving consent if different from Patient:
[Print Name]:
Relationship to Patient:

Self Parent Guardian
In order to better serve the needs of the community, some health care services are available from the center via telemedicine and telehealth. Telemedicine medical services and telehealth services are health care services delivered by physicians and health professionals to patients located at a different physical location using telecommunications or other information technology. Telecommunications or other information technology may also be used for virtual check-ins, e-visits, initial evaluations, screenings, and pre and post visit communication by center staff. Providers may include, but are not limited to, Physicians, Advanced Practice Registered Nurses, Physician Assistants, Professional Counselors, Marriage and Family Therapists, Clinical Social Workers, and Psychologists.

Information shared may include patient medical records, medical images, medical audio or video files, two-way audio and video, and output data from medical devices. The systems used by the center to transmit and receive this information will incorporate network and software security protocols intended to protect the confidentiality of the patient’s identity and information.

I hereby and voluntarily consent to authorize the center’s healthcare providers to provide health care services to me via telemedicine and/or telehealth.

I understand the following:
- The same standard of care applies to health care services delivered via telemedicine and/or telehealth as applies to an in-person visit.
- The laws that protect the privacy and confidentiality of health care information apply to health care services delivered via telemedicine and/or telehealth.
- I will not be physically in the same room as my healthcare provider. I will be notified of, and my consent obtained, for anyone other than my healthcare provider present in the room.
- There are certain hazards and risks connected with all forms of treatment, regardless of the medium used, and my consent is given knowing this.
- There are potential risks to using technology, including service interruptions, interception, and technical difficulties. If it is determined that the telecommunications or information technology is not adequate, the visit may be discontinued.
- I have the right to refuse to participate or decide to stop participating in a telemedicine/telehealth visit at any time.
- I understand that this visit may need to be converted into an in-person visit for situations and/or cases that require a physical exam in order to determine a diagnosis and for appropriate treatment and care.
- The center and the center’s healthcare providers have no liability or responsibility for the accuracy or completeness of the medical information submitted to them or for any errors in its electronic transmission.
- I may consent to my medical record or a report containing an explanation of the treatment provided being sent to my primary care physician.
- This informed consent for telemedicine and/or telehealth is valid and remains in effect as long as I am a patient of the center, until I withdraw my consent, or until the center changes its services and asks me to complete a new consent form.
My signature on this form indicates that:

1. I certify that I have read and fully understand the foregoing consent and that the facts indicated above are true.
2. I realize that although every effort will be made to keep all risks to a minimum, risks can be unpredictable both in nature and severity.
3. I understand that midlevel providers (Physician Assistants and Advanced Practice Registered Nurses) may be involved in my treatment and I consent thereto.
4. I understand that I may be asked to sign a separate informed consent form for certain Treatment(s) that require such.
5. I hereby voluntarily give my consent to receive health care services via telemedicine and/or telehealth.
[Signature of Patient/Legal Representative]

Clear
Print Name:
If signed by other than Patient, indicate relationship:

Clear
[Signature of Witness]

Clear
Print Name of Witness:
Date/Time:

Month Day Year
Date
Interpreter/Translator to complete when applicable:

I have accurately and completely read/translated the foregoing document to:
Patient or Patient's Legal Representative's Name:
Representative's Primary Language:
S/He understood all of the terms and conditions and acknowledged his/her agreement and consent thereto by signing the document in my presence.
[Signature of Interpreter/Translator]

Clear
Print Name of Interpreter/Translated By:
Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:

Texas Medical Board Attention: Investigations 333 Guadalupe, Tower 3, Suite 610 P.O. Box 2018, MC-263 Austin, Texas 78768-2018

Assistance in filing a complaint is available by calling the following telephone number:
1-800-201-9353
For more information, please visit our website at www.tmb.state.tx.us.
Should be Empty:

OPTIONAL RELEASE OF INFORMATION FORM:

Please provide patient with a copy of the “Notice of Privacy Practices” at this time.

UDS Federal Reporting Requirements

Identifying Migrant Patients:

CONSENT PAGE

Authorization of Shared Information

Provider Level

General Consent

Patient’s Rights and Responsibilities

Notice of Privacy Practices

1-800-201-9353