Lander Patient Registration Form

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!
Patient First Name: *
Please use Legal Name
Patient Last Name: *
Please use Legal Name
Patient Middle Initial(s): *
Patient Preferred Name:
Patient Date of Birth (DOB) *

Month Day Year
Date
Patient Sex at Birth *

Male Female Decline to Specify
Patient Mailing Address *

Street Address

City State / Province

Postal / Zip Code
Patient Home Phone Number: *

Area Code Phone Number
Patient Cell Phone Number *

Area Code Phone Number
What is your marital status? *

Divorced Married Single Domestic Partnership Separated Widowed/Widower
Patient Social Security Number (000-00-0000)
Leave blank if unknown or if Patient does not have a Social Security Number.
Patient Email Address *
example@example.com
Are you interested in accessing our patient portal or using our mobile app,? *

Yes No
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.
Responsible Party Name: *

First Name Last Name
Employer: *
This information aids in verification of medical and dental insurance benefits. Please enter N/A if you prefer we don't have the information.
Responsible Party Social Security Number: *
You may enter "Same" if the patient is the responsible party. You may enter N/A if you don't have this information or if the responsible party does not have a social security number.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Patient's Relation to Responsible Party: *
Responsible Party Date of Birth (DOB) *

Month Day Year
Date
Responsible Party Sex: *

Male Female Decline to Specify
Responsible Party Phone Number: *

Area Code Phone Number
Insurance Information
I _____ (select below) have health insurance coverage. *

do do not
Insurance Company: *
Policy Holder Employer (if different from Responsible Party) *
Enter "Same" if Policy Holder is Patient or Responsible Party
Policy or Member ID *
This number is unique to you or the patient and is often a mix of letters and numbers. Enter "N/A" if you are uninsured.
Policy Holder Name (if different from Responsible Party)

First Name Last Name
Policy Holder Date of Birth (if different from Responsible Party)

Month Day Year
Date
Policy Holder Social Security Number (if different from Responsible Party): *
You may enter "Same" if the patient is the Policy Holder.
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.
What is your household annual income? *
Enter as a yearly gross amount ($xx,xxx)
How many people are dependent on the income listed above? *
This includes yourself and any household members that share or rely on the income source.
Are you interested or in need of financial assistance? *

Yes No
Veteran Status *

Veteran Not a veteran Choose not to disclose
Homeless Status: *

Yes, I am homeless No, I am not homeless I live on the street I live in a shelter I live in transitional housing I am doubling up with someone else
Agricultural Status in the last 3 years: *

None Migrant Seasonal Choose not to disclose
Student Status *

I am a full-time student I am a part-time student I am not a student
Employment Status (If under age 18, please select 'unemployed' ) *

Employed full-time Employed part-time Unemployed Retired Disabled Choose not to disclose
Racial Group(s): *

African American/ Black Asian Caucasian/White More than 1 race Native American/ Alaskan Native Pacific Islander Native Hawaiian Choose not to disclose
Referral Source: *

Billboard Radio Business/Agency Friend or Family Fair/Festival/Event Hospital/Clinic Internet Search Social Media Newspaper Choose not to disclose
What is your gender identity? (Please leave blank or select "choose not to disclose if under age 18) *

Male Female Transgender - Male/Trans Man/FTM Transgender - Female/Trans Woman/MTF Other Choose not to disclose
Preferred Language: *
Do you need an Interpreter? *

Yes No
Ethnicity: *

□ Hispanic/Latino/Latina □ Non-Hispanic/Latino/Latina □ Chose not to Disclose
Do you think of yourself as: (Please leave blank or select, "Choose not to disclose" if under age 18) *

Lesbian or Gay Straight (Not lesbian or gay) Bisexual Something else Don't know Choose not to disclose
What pronouns do you use? *

He/him She/her They/them Chose not disclose
Primary Medical Care Provider *
Preferred Pharmacy *
My pharmacy isn't listed:
Please only answer if your preferred pharmacy was not in the drop down list
Dental Provider *
Do you have an Advance Directive, Living Will or Power of Attorney? *

Yes (You may provide a copy if you wish) No
Emergency Contact *

First Name Last Name
Emergency Contact Relationship to Patient *
Emergency Contact Phone Number *

Area Code Phone Number
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.
I _________ (select below) to provide a Protected Health Information (PHI) Designee for myself or my child.

Opt (I opt to provide a PHI Designee for myself or my child) Decline (I decline to provide a PHI Designee for myself or my child)
Name of Designee and Relationship to Patient:

Full Name Relationship to Patient
Phone Number

Area Code Phone Number
Name of Designee and Relationship to Patient: (#2):

Full Name Relationship to Patient
Phone Number

Area Code Phone Number
Name of Designee and Relationship to Patient: (#3):

Full Name Relationship to Patient
Phone Number

Area Code Phone Number
Signature *

Clear
Date *

Month Day Year
Date
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:
Yes:*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
Yes:* I will make every attempt arrive to my appointment on time.
Yes:*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.
Yes:* I have been given the opportunity to ask any questions I have about my care through CHCCW.
Yes:*I can request a copy of all authorization documents such as Notice of Privacy Practices (HIPAA), Patient responsibilities, and CHCCW Responsibilities and Duties.
Yes:*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.
Signature: *

Clear
Date *

Month Day Year
Date
Full name and relationship to patient if the patient cannot complete or sign this document:

Full Name Relationship
Should be Empty:

Community Health Center Pediatrics

Patient Registration Form

RESPONSIBLE PARTY INFORMATION

Insurance Information

HEALTH CENTER FUNDING INFORMATION

*Note - If you are completing this form for another patient or a minor patient, please answer questions from their point of view.

PROTECTED HEALTH INFORMATION DESIGNEE

AS A PATIENT, I AGREE TO THE FOLLOWING:

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