Hill County Family Planning Intake Paperwork

PATIENT INTAKE FORM

Hill County Family Planning 302 4th Ave. Havre, MT PH: 406-400-2416 Fx: 406-265-6976
Who is responsible for bill?*
Do you have medical insurance?*

YesNo
IF RESPONSIBLE PARTY IS OTHER THAN YOU:
Name*
Date of Birth

MonthDayYear
Date
Relationship to Patient*
Address

Billing Address

Street Address Line 2

CityState

Zip
Cell Phone*
Work Phone
Who is insurance under?*
Insurance Information: How do you want to provide your insurance information?*
Take a photo of front AND back of your insurance cards*

Cancelof
Insurance Company Name*
ID Subscriber*
Group #*
Policy Holder Name*
SSN
Their Phone Number
Date of Birth

MonthDayYear
Date

PATIENT INTAKE FORM

Hill County Family Planning 302 4th Ave. Havre, MT PH: 406-400-2416 Fx: 406-265-6976
We receive partial funding from Federal and State grants. Our continued services rely heavily on your payments and donations. You will never be denied services because of an inability to pay.

To ensure that everyone can afford our services, our charges are based on a sliding fee scale. This information is required to determine your fees and as a condition of the grants we receive to bring affordable services to our community. We will not share your income information with anyone else.

We require the below information from all clients whether you have insurance or not. We encourage you to use your insurance whenever it is available, and you will never pay more by using your insurance than you would without it.

All our visits are confidential, however, when we bill insurance, some insurance carriers send information about your care to the policy holder.
Do you want fees reduced on a sliding fee scale?*

YesNo
How do you want to report your gross income (income before taxes)?*
Gross Income*
Income before taxes
# of people in home*
All our visits are confidential, however, when we bill insurance, some insurance carriers send information about your care to the policy holder.*

Yes, bill my insuranceNo, do not bill my insurance. I'll pay on the sliding fee scale instead
Would you like to designate a family member or other individual with whom the provider may discuss your medical condition?*

YesNo
May list up to three people
Name
Relationship
Phone Number
Please enter a valid phone number.
Name
Relationship
Phone Number
Please enter a valid phone number.
Name
Relationship
Phone Number
Please enter a valid phone number.
Have you served in the active military, naval, or air service, which includes full-time service in the Air Force, Army, Coast Guard, Marines, Navy, or as a commissioned officer of the Public Health Service or National Oceanic and Atmospheric

Administration or served in the National Guard or Reserves on active-duty status?
YesNoDecline
Patient Name (Print)
Signature (Patient/Personal Representative)

Clear
Relationship to Patient*
ACKNOWLEGEMENTS: All 3 of these documents will be e-mailed to you have completing intake paperwork
Acknowledgement of Cosumer Bill of Rights: I acknowledge receipt of the Consumer Bill of Rights
Initials*
Acknowledgement of Cosumer Privacy Practices: I acknoledge receipt of the Privacy Practices
Initials*
Acknowledgement of Cosumer Payment Policy: I acknoledge receipt of the Payment Policy and agree to abide by it
Initials*
CONSENT & ASSIGNMENT

I consent to integrated medical, mental health, behavioral health and dental services for me or the individual for whom I am the personal representative and hereby accept responsibility to pay for such services. I know that it is my choice to have services and can change my mind about receiving services at/One Health. In the event I receive family planning services, I understand that such family planning services are provided on a voluntary basis and are not a pre-requisite to eligibility for, or receipt of, any other services or programs of Hill County Family Planning/One Health. Individuals 18 years of age and younger may consent to the receipt of family planning services without parental notification or consent. All information as to personal facts and circumstances obtained by/One Health staff will be held strictly confidential and will not be disclosed without your written consent, except as necessary to provide services to you or as required by law, with appropriate safeguards for confidentiality. I understand that I have the right to receive free language interpreter services. I understand that I must tell the staff if these services will be helpful to my understanding of the written or spoken information given during my healthcare visits. Hill County Family Planning/One Health as my lawful agent and assign to hereby designate Hill County Family Planning/One Health any benefits for medical, dental, behavioral health, mental health, Hill County Family Planning/One Health which I may be entitled to. or any other services I receive from You may ask for a copy of this form or any form that you sign.

I further consent to receiving the services described above via telehealth if it is necessary or appropriate for the current situation. Telehealth uses electronic communications, such as real time audio, video, and data communications, so health care providers at different locations can share a patient's health information to diagnose, consult, and/or treat the patient. To protect the privacy and security of patient health information, all electronic communications used for telehealth comply with network and software security protocols. As with any health care service, there are benefits and possible risks with the use of telehealth. The benefits of using telehealth include improved access to health care and the expertise of providers and/or specialists who are not physically located in the geographic area. Possible risks of using telehealth include possible delay in diagnosis or treatment due to technical difficulties with equipment; information being sent is not sufficient to allow for a complete medical exam by the offsite provider; information may be lost when being sent due to technical failures; and despite security protocols being in place, the privacy of patient health information may be compromised when sent electronically. If I participate in a telehealth session where I am located outside of the clinic, I understand that there is potential for other people to overhear sessions if I am not in a private place. In such cases, I understand that it is my obligation to take reasonable steps to ensure my privacy. I have the right to withhold or withdraw my consent to the use of telehealth without affecting my right to future care or treatment. By signing in the space below,

I consent to receive services via telehealth.
Patient Name (Print)*
Relationship to Patient*
Signature (Patient/Personal Representative)*

Clear
Patient Name (Print)*
Relationship to Patient*
Signature (Patient/Personal Representative)*

Clear

Click "submit" to finalize your paperwork

We look forward to seeing you.
Should be Empty:

	Yes	No
Eye Problems (except glasses & contacts)
Hearing Problems
Heart Disease, murmur, high blood pressure
High Cholesterol/Triglyceride
Blood Clots in arms/legs/chest
Heart attack or stroke
Breathing problems or asthma
Breast lumps or nipple discharge
Tuberculosis or exposure to tuberculosis
Stomach or bowel problems
Gall bladder disease
Liver disease (hepatitis, mono, jaundice, cirrhosis)
Kidney or bladder problems
Burning urination and/or blood in urine
Arthritis or osteoporosis
Gout
Thyroid problems
Diabetes
Migraines or frequent headaches
Epilespsy or convulsions
Blood problems (sickle cell anemia, hemophilia, low iron)
You or YOUR parents had a blood transfusion, tissue/organ transplant or artificial insemination?
Depression or emotional problems

	Yes	No
Measles, mumps rubella (MMR)
Tetanus, diphtheria, pertussis (td-Tdap)
Hepatitis A
Hepatitis B
Varicella (chickenpox)
Human Papilloma virus (HPV)

	Yes	No
Chlamydia
Gonorrhea
Gential Warts/Human Papilomavirus (HPV)
Syphilis
Herpes
Trichomoniasis
Non-gonococcal urethritis (NGU)

	Yes	No
Ovary Problems
Uterus problems or uterine fibroids
Pelvic Inlafmmartory Disease (PID)
Pain or other problems with sex
Vaginal discharge that itches/burns or has had a bad odor

PATIENT INTAKE FORM

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Medical History

PATIENT INTAKE FORM

Family History

Have your grandparents, parents, brothers or sisters ever had any of the following?

PATIENT INTAKE FORM

Personal Medical History

PATIENT INTAKE FORM

Sexual History

PATIENT INTAKE FORM

Male / Assigned male at birth / MTF

PATIENT INTAKE FORM

Female / Assigned female at birth / FTM

Click "submit" to finalize your paperwork