Intake Form

Name

First NameLast Name

Maiden name

Date of birth

Date

SSN

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Can we leave a voicemail and send text messages to this number?

If yes, what can we say?

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County

Race and Ethnic Origin - Choose at least one (required by the state of Oklahoma)

Hispanic/Latino?

Preferred Pronouns

Sex

Authorization for Release of Protected Health Information for Insurance Discovery and/or Debt Collection

I understand that TVC may need to disclose certain Protected Health Information (PHI) in order to determine my insurance coverage, benefits, and eligibility for services. By signing below, I authorize TVC to share the minimum necessary information with insurance companies, payers, or third-party verification services for the purpose of insurance discovery, eligibility verification, and coordination
of benefits.
This information may include identifying information (such as my name, date of birth, and contact information), service information, and other relevant details necessary to determine insurance coverage.
I understand that this disclosure is permitted for the purpose of payment and health care operations and is conducted in accordance with applicable privacy laws, including HIPAA. I also understand that this authorization allows TVC to obtain information from insurance sources as needed to identify potential coverage for services.

Debt Collection Clause:

I also understand that, in the event I accrue an unpaid balance, efforts will be made to collect on that balance including the use of a third-party debt collection agency. I understand that my personal information will be provided to the debt collection agency in the event that debt collection efforts must be used in an attempt to collect on any unpaid balance owed to The Virtue Center.

I acknowledge that I have read and understand this authorization and voluntarily consent to the release of my information for the
purposes described above.

Signature

Please select the option(s) that best describe your need for services:

Other

How did you hear about us? (Who told you to come here?)

Other:

Financial Information

This helps us determine if you will pay using our sliding scale or if you qualify for state benefits. If your financial information ever changes, please alert the front desk.

Do you have commercial insurance?: **Please provide your insurance card to reception

If answered "Yes" to question above, what is the name of your commercial insurance provider?

Do you have Soonercare / Medicaid?

Household income

Frequency (how often do you get paid this amount?)

How many people in your household are you financially responsible for? (Include yourself)

List any special needs or accommodations:

Are you currently pregnant?

Do you use tobacco products?

If yes, would you like assistance with quitting nicotine use?

If yes, please sign below. "I authorize the Oklahoma Tobacco Helpline to contact me."

Additional information you'd like us to be aware of.

FINANCIAL AFFIDAVIT

ANNUAL INCOME DESCRIPTION: Enter the dollar amount only (no cents), which represents the total combined annual income of the customer and any individuals with which the customer is financially interdependent. If annual income is unknown, multiply the estimated monthly income by 12. As defined by the DMHSAS eligibility criteria, income includes total annual cash receipts before taxes from all sources, with the exceptions noted below: Income includes money, wages, and salaries before any deductions; net receipts from non-farm self-employment (receipts from a person’s own unincorporated business, professional enterprise, or partnership, after deductions for business expenses); net receipts from farm self employment (receipts from a farm which one operates as an owner, renter, or sharecropper, after deductions for farm operating expenses); regular payments from social security, railroad retirement, unemployment compensation, strike benefits from union funds, workers’ compensation, veterans’ payments, public assistance (including Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), and non-federally-funded General Assistance or General Relief money payments), and training stipends; alimony, child support, and military family allotments or other regular support from an absent family member or someone not living in the household; private pensions, government employee pensions (including military retirement pay), and regular insurance or annuity payments; college or university scholarships, grants, fellowships, and assistantships; and dividends, interest, net rental income, net royalties, periodic receipts from estates or trusts, and net gambling or lottery winnings. Income does not include non-cash benefits, such as the employer-paid or union-paid portion of health insurance or other employee fringe benefits, food or housing received in lieu of wages, the value of food and fuel produced and consumed on farms, the imputed value of rent from owner-occupied non-farm or farm housing, and such federal non-cash benefit programs as Medicare, Medicaid, food stamps, school lunches, loans, and housing assistance.

I certify that my income, or lack of income, has been reported in truth and entirety. I understand that if my income circumstances change int eh future, I am required to report the change. I also understand that knowingly making false claims regarding these statements is an offense punishable by law.

Signature