• Community Health Center Pediatrics

    115 Wyoming Street Lander, Wyoming 82520
  • Patient Registration Form

    Please fill out the blanks below with the Patient's information. For questions or if you need assistance please call 307-332-2185. Thank you!
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  • RESPONSIBLE PARTY INFORMATION

    At Community Health Center of Central Wyoming, we collect this information to ensure that our billing department has the most up-to-date information for billing purposes.
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  • Insurance Information

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  • HEALTH CENTER FUNDING INFORMATION

    In order to continue the variety of services that we offer at CHCCW and to continue to receive grant funding, we are required to collect the following information on every person that visits our facility. This information is reported as a cumulative number and not reported on individual patients.
  • *Note - If you are completing this form for another patient or a minor patient, please answer questions from their point of view.


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  • PROTECTED HEALTH INFORMATION DESIGNEE

  • I understand that the individuals identified below will be treated by Community Health Center of Central Wyoming (CHCCW) as individuals involved directly in my or the registered patient’s care and as such CHCCW will be allowed to release the patient’s personal health information to these individuals for the purpose of treatment including making and cancelling appointments, consenting to individual patient care appointments (including vaccinations) or to any medical or dental treatment requiring written or informed consent, payment, or health care operations.

    I further understand that the below-named designees have a right to request and receive a Notice of Privacy Practices from Community Health Center of Central Wyoming (CHCCW). This document is an acknowledgment that the above-named patient or the patient’s legal guardian has supplied CHCCW with one or more contacts, with whom they may use or disclose the patient’s personal health information.  CHCCW has made the Protected Health Information Designee available to patients so that they may identify individuals that have permission to consent to treatment and receive protected health information for the patient in the absence of the patient or the patient’s legal guardian or representative. By signing below, I acknowledge that I have read and understand the above statements and accept the terms.  I voluntarily sign this authorization and understand that my ability to receive health care from CHCCW will not be affected if I decline to provide a PHI Designee.

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  • AS A PATIENT, I AGREE TO THE FOLLOWING:

  • CONSENT TO TREATMENT, AUTHORIZATION FOR MEDICAL RECORDS RELEASE/REFERRAL AND ASSIGNMENT OF BENEFITS AND PATIENT RIGHTS AND RESPONSIBILITIES: I.

    I hereby consent and authorize Community Health Center of Central Wyoming (CHCCW) to furnish me or the above registered patient with necessary medical or dental care. This care may include ancillary care including but not limited to laboratory testing, radiologic examinations and other diagnostic procedures as deemed necessary by the professional staff at CHCCW. I understand that the services recommended to, or provided to me are in my, or the registered patient’s best interest. I understand that I have and reserve the right to revoke this consent at any time and for any reason during my treatment at CHCCW. I consent to be contacted by mail, email, and telephone regarding matters related to my treatment or patient account by CHCCW and entities formally associated with CHCCW.

    I authorize CHCCW to release protected health information to persons or entities directly associated with and engaged in carrying out a treatment plan for the patient. CHCCW may use and release any part of my medical records necessary to the process of billing third party payers for services rendered on my behalf. I clearly understand that all my information will be kept confidential. I consent for CHCCW to use technology, including automated technology such as auto-dialing or pre-recorded messages, to contact me at the address, e-mail address, or telephone number, including any cell phone/wireless number that I have provided; I understand that this information will be used to review, investigate, make payment of a claim, to review records for quality improvement initiatives, audit compliance, utilization management, or complaint resolution. I authorize payment directly to Community Health Centers of Central Wyoming for all medical or dental benefits otherwise payable to me under terms of my insurance. I understand that I am financially responsible for all co-payments, co-insurance, deductibles, and non-covered services. Overpayments on my account at Community Health Centers of Central Wyoming account may be applied to my patient balance.

  • BY AGREEING AND SIGNING BELOW, I SIGNIFY MY UNDERSTANDING AND AGREEMENT:

  • *I will treat the staff and clients of CHCCW with dignity and respect. Verbally expressed profanities and vulgarities toward any staff or other patients of CHCCW will not be tolerated and could be grounds for service termination

  • * I will make every attempt arrive to my appointment on time.

  • *I will make every attempt to cancel appointments at least 2 hours before or it will be considered a “No Show”. Repeat “no shows” could result in you losing privileges to schedule future appointments.

  • * I have been given the opportunity to ask any questions I have about my care through CHCCW.

  • *I can request a copy of all authorization documents such as Notice of Privacy Practices (HIPAA), Patient responsibilities, and CHCCW Responsibilities and Duties.

  • *I understand that I am expected to make every attempt to pay any payment due, co-payment, nominal fee, or co-insurance amount at the time of service, but understand that an inability to pay will never prevent me from being treated at CHCCW.

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