SFCHC Patient Registration Form

Patient Registration Form
Please complete each section of the form below, review our patient disclosures and consent declaration, and electronically sign at the bottom of the page before submitting.

Items with a red asterisk* require an answer.
Patient Name*

First NameMiddle NameLast Name
Are you completing this form for another person?*

YesNo
Where did you hear about SFCHC?*

Friend or FamilyWalk-InNewspaper/MagazineFlyer/PosterSocial Media (Facebook, etc.)Radio/TelevisionOnline Search (Yelp, Google, etc.)WebsiteDoctor ReferralHarbor CaresProvidenceNorth East Valley HCAccess to CareSan Fernando Recovery CenterNational Council on Alcoholism and Drug Dependence (NCADD)Other

AGREEMENT TO PAY FOR TREATMENT
I, the responsible party, hereby agree to pay all the charges submitted by this office during the course of treatment for the patient. If the patient has insurance coverage with a managed care organization, with which this office has a contractual agreement, I agree to pay all applicable copayments, co‐insurance and deductibles, which arise during the course of treatment for the patient. The responsible party also agrees to pay for treatment rendered to the patient, which is not considered to be a covered service by my insurer and/or a third party insurer or other payor.

I understand that San Fernando Community Health Center provides charges on a sliding fee; based on family size and household annual income, and that services will not be refused due to inability to pay at the time of the visit.
Responsible Party*

First NameLast Name
Date*

MonthDayYear
Date
Relationship to patient (if not patient)

ACKNOWLEDGEMENT FOR ADVANCE DIRECTIVES
An Advance Healthcare Directive is a document by which a person makes provision for health care decisions in the event that, in the future, he/she becomes unable to make those decisions.
Please select one option:

I do have an Advance Directive / Living Will / Durable Power of Attorney for medical or health care decisionsI do NOT have an Advance Directive / Living Will / Durable Power of Attorney for medical or health care decisionsI would like further information on Advance DirectivesI would NOT like further information on Advance Directives.
If you do have an Advance Directive, please make sure to send a copy to us, in person or by mail (732 Mott St, San Fernando, CA 91340).

By signing below, I acknowledge I have received information about Advance Directives.
Responsible Party*

First NameLast Name
Date*

MonthDayYear
Date
Relationship to patient (if not patient)

CONSENT FOR TREATMENT
By signing below, I the undersigned patient (or authorized representative, or parent/guardian), consent to and authorize the performance of any treatments, examinations, medical services, surgical or diagnostic procedures, including lab and radiographic studies, as ordered by this office and it’s healthcare providers.
Responsible Party*

First NameLast Name
Date*

MonthDayYear
Date
Signature*
Relationship to patient (if not patient)
Should be Empty: