UHC Patient Registration Form

**Please present your insurance card(s) and photo identification to the front desk along with this form.
First
Middle
Last
Date of Birth

MonthDayYear
Date
Social Security #
Sex

MaleFemale
Preferred Name
Marital Status

SingleMarriedDivorcedSeparatedWidowed
Street address
PO Box
City
State
Zip code
Telephone Home/Cell
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Email
example@example.com
Student

Full TimePart TimeNot a Student
School
Primary language
As a Federally Qualified Health Center, UHC is required to collect demographic information regarding the patients we serve. The information you provide is confidential. Please check Choose Not to Report if you do not wish to answer a specific question.
Race (check one)

American Indian/Alaska NativeAsianBlack/African AmericanMore than one raceNative HawaiianOther Pacific IslanderWhite/CaucasianChoose not to report
Ethnicity (check one)

Hispanic/LatinoNot Hispanic/LatinoChoose not to report
Sexual Orientation

Straight (not lesbian or gay)Lesbian or gayBisexualSomething ElseDont knowChoose not to disclose
Gender Identity

MaleFemaleTransgender Male/Female-to-MaleTransgender Female/Male-to-FemaleOtherChoose not to disclose
Are you a US Veteran?

YesNo
Do you live in public housing?

YesNo
Housing for patient or patient's parent/guardian, if a minor - Please check one

Rent or own homeTransitionalDoubled Up (Live with another person or family)Homeless ShelterStreetChoose not to discloseOther
Annual Family Income (Gross) - please check one

$12,140 or below$12,141 - $16,460$16,461 - $20,780$20,781 - $25,100$25,101 - $29,420$29,421 - $33,740$33,741 - $38,060$38,061 - $42,380$42,381 - $46,700$46,701 - $51,020$51,021 - $55,340$55,341 - over
Family Size

Choose not to discloseOther
Spouse's name
Date of birth

MonthDayYear
Date
Spouse's Telephone
Please enter a valid phone number.
Address
In case of EMERGENCY, we may contact
Name
Phone Number
Please enter a valid phone number.
Related how?
Guarantor Information
Who pays the bill?
Phone Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Relationship
Address

Address

Street Address Line 2

CityState

Zip Code
Employer
Social Security number
Date of birth

MonthDayYear
Date
If Patient is a Minor: (Please complete this section)
Parent/Legal Guardian (1) Full Name
Phone Number
Please enter a valid phone number.
Relationship to Patient
Date of birth

MonthDayYear
Date
Work Number
Please enter a valid phone number.
Parent/Legal Guardian (2) Full Name
Phone Number
Please enter a valid phone number.
Relationship to Patient
Date of birth

MonthDayYear
Date
Work Number
Please enter a valid phone number.
Non Parent/Legal Guardian Designee (authorized to accompany minor)
Full Name*
Related how?
(*The information listed above is Not authorization for a personal representative. A HIPAA release MUST be signed to discuss ANY information.)
By checking this box, I acknowledge I have been I certify that the information given above is true and correct. offered an applicationfor the slide discount program (UHC) and DO NOT want to participate.

I acknowledge
(Patient Signature or Parent/Guardian signature, if patient a minor)

Clear
Date

MonthDayYear
Date
United Health Centers

About Our Notice of Privacy Practices

We are committed to protecting your personal health information in compliance with the law.

The attached Notice of Privacy Practices states:

 Our obligations under the law with respect to your personal health information.
 How we may use and disclose the health information that we keep about you.
 Your rights relating to your personal health information.
 Our rights to change our Notice of Privacy Practices.
 How to file a complaint if you believe your privacy rights have been violated.
 The conditions that apply to uses and disclosures not described in this Notice.
 The person to contact for further information about our privacy practices.

It is our policy to give you a copy of this notice and to obtain your written acknowledgement that you have received a copy of this notice.
Patient Acknowledgement of Receipt

I, hereby acknowledge that I have received a copy of the Notice of Privacy Practices.
Name
Patient's Signature

Clear
Date

MonthDayYear
Date
Signature of Parent or Patient's Representative (if applicable)

Clear
Date

MonthDayYear
Date
Description of Legal Authority to Act on Behalf of Patient
United Health Centers

Conditions of Examination

Contact Information and Instructions

In order to provide you with quality health services with respect for your privacy, we ask that you instruct us on how to get in touch with you to discuss matters such as important lab results and medical follow up, appointment scheduling, billing issues, pharmacy refill orders or potential drug recalls.
Telephone

OK to leave message with detailed informationLeave message with call back number only
Cell Number*
Please enter a valid phone number.
Text Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Written Communication

Mail to home address (such as postcards or letters).Mail to work/office
Address
Email
example@example.com
Consent for Examination and Treatment

I give the designated personnel of United Health Centers, my consent for examination, ordering of appropriate lab test(s), diagnostic procedures and prescribing medication and treatment for
Patient's Name
All procedures will be explained to me. I will have a chance to ask questions about advantages, alternatives, and possible adverse effects.

This consent is valid until revoked.

Responsibility for Payment of Bill: I, the undersigned, understand that I am financially responsible for the services received by the patient and authorize United Health Centers to release any medical information required to receive payment for services renderedto the patient.

Beneficiary Agreement: I request payment of authorized benefits by my insurance carrier be made on my behalf to United Health Centers for services rendered to me by United Health Center, | understand that this request is valid until revoked by me and that I am responsible for any deductibles and co-insurance of allowable charges not otherwise covered.

Content of Form: I certify that I have read this form and understand its contents and that the information given by me is true and correct.
Date

MonthDayYear
Date
If minor, parent/legal guardian's signature is required.

Clear
CONSENT TO COMMUNICATE PROTECTED

HEALTH INFORMATION TO AN AUTHORIZED PERSON

I give permission for United Health Centers to VERBALLY share the information I have described below to be released to the persons I have identified below. This form does not authorize releasing copies of my medical records.

*I understand that my records are protected under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient records, 42 CFR Part 2 and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 CFR Parts 160 & 164 and state confidentiality law governing behavioral health/substance abuse services (GS 122C)
cannot be disclosed without my written consent unless otherwise provided or in the regulations. I understand that the information to be released may contain information regarding alcohol abuse, drug abuse, HIV infection, AIDS or AIDS related conditions, psychological, psychiatric or physical limitations.

I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in reliance on it. I understand that UHC may not condition my treatment based on the signature of this form.
Patient name (please print)
Date of Birth

MonthDayYear
Date
Indicate each person that you approve:
Name
Phone
Relationship

FamilyFriendCaregiverOther/Other Provider
Anything else we need to know about this person?
This consent expires one year from date executed unless other noted here:

MonthDayYear
Date
Patient signature

Clear
Printed name
Date

MonthDayYear
Date
REVOCATION SECTION
I do hereby request that this authorization to disclose health information of (Name of Client) signed by (Name of Person Who Signed Authorization) on (Enter Date of Signature) be rescinded, effective (Enter date). I understand that any action taken on this authorization prior to the rescinded date is legal and binding.
Name of Client
Person who signed Authorization
Date of signature

MonthDayYear
Date
Rescind Date

MonthDayYear
Date
Signature of Patient

Clear
Date

MonthDayYear
Date
Signature of Witness

Clear
Date

MonthDayYear
Date
Should be Empty: