English Registration Packet

Welcome to Hope Health!

Hope Health welcomes new patients daily. The first step to becoming a Hope Health patient is to complete the necessary forms.

Services offered at Hope Health

Family Medicine	Pediatrics	Women's Health
Behavioral Health	Psychiatry	Dental (Adult & Pediatrics)
Lab Work	Diabetes Education	Outreach & Enrollment

Required Documentation

Please provide the following documentation, as applicable, with your completed registration form.

You will be able to upload your documents at the end of the registration form.

Photo I.D. (a Photo I.D. is required for all patients, please provide one of the following)

Driver's License
State Identification (I.D.) Card
Military I.D.
Passport
School I.D. (under 18)
Permanent Resident Card
Certificate of Citizenship
Certificate of Naturalization

Insured Patients (Medicaid/Medicare/Private Insurance)

Current Insurance Card - we need to make a copy of the front and back of your card at each visit.

Proof of Income: Patients may be eligible for discounted services on a Sliding Fee Scale based on household size and income. If you qualify, you will pay a discounted amount for your care at Hope Health. If you wish to be considered for the Sliding Fee Scale, you must submit proof of income. Please see the following guidelines.

Tax Return (most recent) or Pay Stubs (equivalent to one month)

Weekly = 4 pay stubs	Bi-weekly = 2 pay stubs
Semi-Monthly = 2 pay stubs	Monthly = 1 pay stub

Additional Income (required if applicable):

Social Security Income
Alimony
Disability Income
Child Support
Food Stamps (SNAP) Approval Form - must be the form that shows the household income

Dependents (dependents are only counted if you provide one of the following):

Tax Return (most recent) with dependent(s) listed
Birth Certificate
Marriage License
Adoption Papers
Proof of Legal Guardianship

The above referenced documentation is required to qualify for the sliding fee discount program. Medical, Dental, Behavioral Health and Labs have separate sliding fee discounts.

Each patient will be expected to pay for service at the time of the appointment. Fees or co-pays may vary depending on service(s).

If you have any questions relating to expected charges, you may inquire with the front desk personnel at the time of your visit.

Patient Registration Form

All Information is Strictly Confidential
Patient Information
Name*

First NameMiddle NameLast Name
Suffix
Address*

Street Address

Street Address Line 2

City

Zip
County*
Date of Birth*

MonthDayYear
Social Security No.*
Cell/Primary Phone *
May We Leave a Message?*
Would You Like to Receive Text Messages? *
Work Phone
May We Leave a Message?*
Alternate Phone
Email
Preferred Method of Contact*
Is Patient a Minor (under 18 yrs. old)?*
Is the Patient an Emancipated Minor*
If yes, legal documentation is required
Does Someone Other than the Parent have Legal Guardianship of the Patient?*
Custodial Parent Name*

First NameLast Name
Custodial Parent Date of Birth*

MonthDayYear
Custodial Parent Social Security No.*
Custodial Parent Address *

Street Address

Street Address Line 2

City

Zip Code
County*
Custodial Parent Cell/Primary Phone*
May We Leave a Message?*
Non-Custodial Parent Name

First NameLast Name
Non-Custodial Date of Birth

MonthDayYear
Non-Custodial Address

Street Address

Street Address Line 2

City

Zip Code
Non-Custodial Cell/Primary Phone
May We Leave a Message?
Legal Guardian's Name*

First NameLast Name
Legal Guardian's Date of Birth*

MonthDayYear
Legal Guardian's Social Security No.*
Legal Guardian's Address *

Street Address

Street Address Line 2

City

Zip Code
Legal Guardian's Cell/Primary Phone*
May We Leave a Message ?*

Patient Demographics
Current Gender*
Gender Identity*
Sexual Orientation*
Preferred Pronoun*
Marital Status*
Name of Spouse/Partner*

First NameLast Name
Spouse or Partner's Phone *
Homeless Status*
Race*
Ethnicity*
Student Status*
Preferred Language*
(English, Spanish etc.)
Do You Need a Translator?*
Migrant Worker Status*
Are you a Veteran*

Financially Responsible Party

Guarantor
Name of Person Financially Responsible for Patient*

First NameLast Name
Relationship to Patient*
Address *

Street Address

Street Address Line 2

City

Zip Code
Date of Birth*

MonthDayYear
Date
Social Security No.*
Cell/Primary Phone*
Insurance Information
Do You have Insurance*
What Type of Insurance Do You Have?*
Name of Insurance Company*
(example: Blue Cross Blue Shield)
Subscriber's Name*

First NameLast Name
Subscriber's Date of Birth*

MonthDayYear
Date
Member I.D.*
Group #*
Do you have Secondary Private Insurance?*
Name of Secondary Insurance Company*
(example: Blue Cross Blue Shield)
Subscriber's Name*

First NameLast Name
Subscriber's Date of Birth*

MonthDayYear
Member I.D.*
Group #*
Medicare # *
Do You have Medicare Secondary Insurance*
Medicare Secondary Insurance Name*
Medicare Secondary Insurance Policy #*
Medicaid Plan *
(Amerigroup, Parkland, Molina, Superior)
Medicaid # *
Emergency Contact

(at least one emergency contact is required)
Name of Friend or Relative*

First NameLast Name
Relationship to Patient*
(example: friend, sister, cousin)
Phone No.*
Name of Friend or Relative

First NameLast Name
Relationship to Patient
(example: friend, sister, cousin)
Phone No.
Reason for Visit
Please Describe the Reason for Your Visit:*
Are You Pregnant?*
How did you hear about us?*
Private Insurance Authorization for Assignment of Benefits/Information Release
I, the undersigned, authorize payment of medical benefits to Ellis County Coalition for Health Options dba Hope Health for any services furnished to me by the physician. I understand that I am financially responsible for any amount not covered by my contract. I also authorize you to release my insurance company or their agent information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits.
Patient, Parent, or Guardian Signature*

Clear
Today's Date

MonthDayYear
DateHourMinutesAM/PM Option

Patient Household & Income Information

Hope Health is a Federally Qualified Health Center (FQHC) and can offer discounted services to patients based upon financial ability or inability to pay. This program requires us to obtain income and household information from each patient for whom we provide services. If you qualify, you will pay a discounted amount for your care at Hope Health

If you wish to be considered for the Sliding Fee Scale, please complete Section I-III of this form in its entirety. Failure to submit all the required information, will delay in the determination of discounted services.
Do you wish to be considered for the Sliding Fee Scale?*
I DO NOT wish to be considered for the Sliding Fee Scale and I understand services will be priced using customary fees (please sign below)
Patient or Parent/Guardian Signature (if patient is under 18 years)*

Clear
Today's Date

MonthDayYear
AM/PM Option
SECTION I: Head of Household
Name of Head of Household*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
# of Dependents*
Proof of Dependents is Required
Date of Birth*

MonthDayYear
Date
Social Security No.*
Marital Status*
SECTION II: Household Income
Please complete for each adult household member who is employed or has any source of income

Proof of income and dependents is required to qualify for discounted services. Otherwise, services will be priced using customary fees.

Unable to prove income or claiming zero income? We have options for you. Please contact us at 972-923-2440
* If more space is needed, click + Add Row
SECTION III - Members of the Household

(list all individuals in household, including the Head of Household first)
*If more space is needed, click + Add Row
By signing below, I agree that the Hope Health staff may contact each employer listed and/or other agencies to confirm my income. I will provide Hope Health with proof of income for the purpose of calculating my discount, if I qualify. I will be asked to document my income regularly (annually if tax return is provided/monthly if paystubs or insurance is provided), and I agree to inform Hope Health if there are any changes to income, household size, or insurance coverage indicated above. I understand that certain services and/or items cannot be discounted. I agree to pay my copay at the time of services. I hereby certify that the information I have provided is complete and correct to the best of my ability.
Patient or Parent/Guardian Signature (if patient is under 18 yrs. old) *

Clear
Date

MonthDayYear
AM/PM Option
OFFICE USE ONLY

Date Recieved: _____________  Patient Chart #____________________

Sliding Scale (circle one):    A B C D No Income Full Cost

Insurance (circle one):  Medicaid CHIP Medicare Private Ins. E.C. Indigent

Type of Income Provided: _________________________________________

Eligibility:  From ___________________ To ____________________

Patient Notified of Fee (circle one): Yes No

Employee's Initials: ______________________________

Patient's Rights & Responsibilities

Please read the Patient's Rights & Responsibilities below in PDF form. For easier reading, you can click the + to zoom in or you can click the arrow to download the document to your device.
Notice of Privacy Practices

Please read the Notice of Privacy Practices below in PDF form. For easier reading, you can click the + to zoom in or you can click the arrow to download the document to your device.
PATIENT ACKNOWLEDGEMENT
Acknowledgement of Receipt of the Notice of Privacy Practices

This notice describes how health information about me may be used and disclosed and how I can get access to this information. Copies of our Notice of Privacy Practices may be found on our website, www.hopehealthtx.org, under the Patient Information Section. You may also review this Notice in our patient lobbies, or ask for a printed copy at the front desk. I hereby acknowledge that I have reviewed a copy of the Hope Health Notice of Privacy Practice.
Initial*
Acknowledgement of Review of Patient’s Rights and Responsibilities

This notice describes the patient responsibilities to Hope Health. I agree to all the conditions as described in the Patient’s Rights and Responsibilities. If I have further questions regarding the Patient Rights and Responsibilities, I may direct them to the clinic staff.
Initial*
Acknowledgment of Review of Zero Tolerance Notice

This notice is listed within the Patient’s Rights and Responsibilities. It describes the patient’s responsibility to treat Hope Health staff and patients with courtesy and respect. I hereby acknowledge that Hope Health maintains a zero-tolerance policy of abuse, harassment, or violence of any kind.
Initial*
Consent for Treatment

I hereby and voluntarily consent to authorize the clinic’s Providers to provide health care services to me at the clinic. The health care services may include, without limitation, routine physical and mental assessment; diagnostic and monitoring tests and procedures; examinations and medical and/or dental treatment; routine laboratory procedures and tests; x-rays and other imaging studies; administration of medications; and procedures and treatments prescribed by the clinic’s healthcare Providers. The health care services also may include counseling necessary to receive appropriate services including family planning (as defined by federal laws and regulations). A person who signs a general consent for the performance of medical tests or procedures is not required to also sign or be presented with a specific consent form relating to medical test or procedures to determine HIV infection, antibodies to HIV, or infections with any other probably causative agent of AIDS that will be performed on the person during the time in which the general consent form is in effect. I understand that I will be asked to sign a separate informed general consent for vaccines administered to me and that I will be asked to sign a separate informed consent for the influenza (flu) vaccine. I understand that there is a separate consent form that I may be asked to sign for procedures performed in the office. I understand that there are certain hazards and risks connected with all forms of treatment, and my consent is given knowing this. I understand that this consent is valid and remains in effect as long as I am a patient of the clinic, until I withdraw my consent, or until the clinic changes its services and asks me to complete a new consent form.
Initial*
Co-Pay Policy

Some health insurance carriers require the patient to pay a co-pay for services rendered. It is expected and appreciated at the time the service is rendered for the patient to pay at EACH Visit. If proof of income is provided, you may qualify to use our sliding fee scale for services that are not covered by your insurance or for charges that are applied to your deductible. This does not apply to charges that require a co-pay or co-insurance payment determined by your Insurance Company. Thank you for your cooperation in this matter.
Initial*
Cancellation / No Show Policy

We understand there may be times when you miss an appointment due to emergencies or obligations to work or family. However, we urge you to call 24 hours prior to canceling your appointment. If you do not cancel 24 hours prior to your appointment, it will be considered a missed appointment. If you miss three (3) or more appointments within a 3-month period, you may be limited to scheduling future appointments. In addition, a no-show fee of $35 will be charged to your account.
Initial*
Cash-Pay Patients

I do not have health insurance and will be responsible for services rendered at Hope Health. I agree to pay the full and entire amount for treatment given to me or to the below named patient on the date services are rendered. I also understand that I will be considered as a “full-cost” patient if proof of income is not provided or if my income is above 200% of the Federal Poverty Level Guidelines.

(write n/a if not cash pay)
Initial*
Authorization to Release Information

I hereby authorize any Hope Health staff or providers to engage in any verbal or written communication to the person(s) listed below regarding my medical history, medical records, appointments and/or information pertaining to my account and/or billing history with Hope Health. I understand that if I do not list any names that family members and/or friends will not be told any information regarding my visit(s) with Hope Health.
Initial*
May we leave a message?
May we leave a message?
May we leave a message?
I further authorize Hope Health to release to agencies that I am being referred to, any information acquired in the course of my or the below named patient's examination and treatment as needed
Initial*
I have read and understand the above information, and I agree to the terms described. I have had the opportunity to ask questions and have them answered to my satisfaction. If I am not the patient, I certify that I am authorized by law to agree to these conditions of treatment on behalf of the patient.
Initial*
Patient Name*
Patient or Parent/Guardian Signature*

Clear
Name of Parent or Guardian (only if patient is under 18 years old)
Name of Guarantor (only if Guarantor is not the patient or parent)
Date

MonthDayYear
DateHourMinutesAM/PM Option
Please upload your documents HERE

Browse Files

Cancelof
Should be Empty:

Patient Registration Form

Patient Information

Patient Demographics

Financially Responsible Party

Insurance Information

Emergency Contact

Reason for Visit

Private Insurance Authorization for Assignment of Benefits/Information Release

Patient Household & Income Information

SECTION I: Head of Household

SECTION II: Household Income

Please complete for each adult household member who is employed or has any source of income

SECTION III - Members of the Household

Medical Records Release Form

PATIENT INFORMATION

MY AUTHORIZATION

PURPOSE

INFORMATION TO BE DISCLOSED

TERM

REDISCLOSURE

REFUSAL TO SIGN/RIGHT TO REVOKE

QUESTIONS

SPECIFIC AUTHORIZATIONS

FEES

Social Determinates of Health (PREPARE) Questionnaire

Patient's Rights & Responsibilities

Notice of Privacy Practices

PATIENT ACKNOWLEDGEMENT

Acknowledgement of Receipt of the Notice of Privacy Practices

Acknowledgement of Review of Patient’s Rights and Responsibilities

Acknowledgment of Review of Zero Tolerance Notice

Consent for Treatment

Co-Pay Policy

Cancellation / No Show Policy

Cash-Pay Patients

Authorization to Release Information

I further authorize Hope Health to release to agencies that I am being referred to, any information acquired in the course of my or the below named patient's examination and treatment as needed