Patient Intake Form

Patient Intake Form

If you have any questions about this form, please contact our School Based Coordinator, Blanca Resinos, bresinos@uchcla.org, or (323) 233-3100 x119
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Primary Mobile/Cell Phone Number*
Other Contact/Home Phone Number*
Social Security Number (if applicable)
Primary Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide an Emergency Contact
Name of Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
What is your Primary Language?*
Do you require translation services if you need to communicate in English?*

YesNo
What is your Race?*
What is your Ethnicity?*

Please answer the following questions:*

	Yes	No
Are you a migrant farm worker?
Are you a Veteran?
Are you a seasonal farm worker?
Are you homeless?
Do you have limited English language proficiency?
Do you live in public housing?

Patient's Mother's Name*

First NameLast Name
Patient's Father's Name*

First NameLast Name
How many people live in your household (including yourself)?*
What is your approximate annual household income?*
What is your Gender Identity?*

MaleFemaleTransgender Male/Female-to-MaleTransgender Female/Male-to-FemaleOtherChose not to disclose
What is your Sexual Orientation?*

Lesbian or GayStraight/Heterosexual (not lesbian or gay)BisexualSomething elseDon’t knowChose not to disclose
Marital Status*

SingleMarriedDivorcedWidowed
Insurance Information
Please take a picture of the following:
Take Photo of the front of your Identification/Driver's or other ID Card if you have any*
Take Photo of the Front of Insurance Card (if applicable)
Take Photo of the back of Insurance Card (if applicable)
Applicant’s Statement:

I understand that this eligibility certification form is a legal document and certifies that the information on this form is true to the best of my knowledge. I acknowledge that such information is subject to verification and that falsification of the form shall be grounds for termination from the program. All such information will be kept confidential.

I give permission for myself/my child to receive treatment by UCHC Mobile Unit at the School Based Site, and without the parent/guardian present.

I understand that I may have my prescriptions filled at any pharmacy.
Signature of Patient or Patient's Representative/Guardian:*

Clear
Date Signed*

MonthDayYear
Date
Patient's Representative or Guardian's Printed Name (if someone other than the patient is signing this form):

First NameLast Name
Relationship to Patient:
**Staff Use Only**
Payment Method
Based on COMBINED LEVEL OF HOUSEHOLD INCOME and Family Size Check off appropriate Poverty Level income level (Use Table I-CSBG Poverty Income Guidelines)

Up to 75%75%-100%101%-125%126%-150%Above 150%
Staff Name

First NameLast Name
Should be Empty:

Patient Intake Form

Patient Information

Please provide an Emergency Contact

Insurance Information

**Staff Use Only**

Staff Use Only