Patient Application and Recertifications

Patient Application and Recertifications
To complete this application will need the following documents.Application will not be approved until we have all documents.
- A valid picture ID (driver license, visa, passport, green card, state-issued ID card)
- Proof of residency (rental lease, utility bill showing current address, notarized letter from landlord)
- Proof of income (A wage inquiry from the Georgia Department of Labor (everyone needs to submit the wage inquiry)with 1 month of check stubs; or if check stubs are not available, a statement of gross amount received from your employer on company letterhead, if you receive Supplemental Security Income (SSI), an award letter with monthly amount is required.) If not working we need a support letter from the person helping you with the dollar amount .If you are a contract worker we need your 1099.
Are you a new patient applying or an existing patient who is recertifying their information? Please select the option below that applies to you.*

New PatientExisting Patient
Have you been referred to Men's Clinic at Physician's Care Clinic by the DeKalb County Board of Health?*

YesNo
How did you hear about Physicians' Care Clinic?*

Word-of-mouth from friends or familyReferral from Doctor or Medical PartnerSearch Engine (Google, Bing, Yahoo, etc)Social Media (Facebook, Instagram, etc)Other
How many years have you lived in DeKalb County, Georgia?*

Patient Contact Information
Full Name (First, Middle, Last)*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
May we leave a voicemail, text, or email to contact you?*

YesNo
Email Address*
If you do not have an email address, then insert "N/A". However, you will at least need a valid cellphone number to proceed.
Cell Phone*
Please enter a valid phone number.
Home Phone*
Please enter a valid phone number. If you only have a cell phone, then insert your cell phone number.
Work Phone*
Please enter a valid phone number. If you only have a cell phone, then insert your cell phone number.

Emergency Contact Information
Emergency Contact Name*

First NameMiddle NameLast Name
Relationship to Patient*
e.g., mother, father, spouse, friend, etc
Emergency Contact Email Address*
If they do not have an email address, then insert "N/A". However, you will at least need a valid cellphone number to proceed.
Emergency Contact Cell Phone Number*
Please enter a valid phone number.
Emergency Contact Home Phone Number*
Please enter a valid phone number. If they only have one phone number, then use that one.
Emergency Contact Preferred Language*
Emergency Contact Address*

Street Address

Street Address Line 2

CityState

Zip Code
Please print your initials below to confirm your emergency contact information:*
e.g., If your name is Jane Doe, you would insert "JD"

Household Size and Income
Total Number of Household Members*
Household Size: (include yourself and any persons related by birth, marriage, adoption, or legal dependent living together)*

Household Income*

	Amount $ in the last 4 weeks
Employer Work or Unemployment
Spouse or Adult Family Member
Social Security Income (Disability)
Social Security Income (SSI)
Alimony / Child Support
Pensions (Veteran's or Retirement)
Monthly Total
Annual Total

Submit Proof of Income*

(A wage inquiry from the Georgia Department of Labor with 1 month of check stubs; or if check stubs are not available, a statement of gross amount received from your employer on company letterhead, if you receive Supplemental Security Income (SSI), an award letter with monthly amount is required.)
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Please sign your signature below*

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Acknowledgement of Receipt of Privacy Notice
Click here to view the Notice of Privacy and Confidentiality Practices Form & the Patient Rights & Responsibilities

I acknowledge that I have received a copy of the Notice of Privacy Practices for the Physicians’ Care Clinic. I also acknowledge that I have been provided with an opportunity to ask questions and receive answers regarding the Notice and its contents.
Please sign your signature below

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Patient Acknowledgment and Authorization for Treatment
In applying for treatment in the Physicians’ Care Clinic (PCC):
1. I understand that the Physicians’ Care Clinic is a private not-for-profit all volunteer supported clinic. No government funds are received for patient care. The clinic operates through the generosity of private donors.
2. I understand health care provided by PCC will be by volunteer staff and volunteer health care providers who; by appointment only; and only during regular clinic hours. I authorize the examination, diagnostic procedures, and treatment deemed necessary by the doctor(s), other health care professional(s) and whomever she/he may designate as assistants. I understand Physicians’ Care Clinic is staffed by volunteers (physicians, PAs, CNPs, pharmacists, nurses, students). I accept and consent to treatment and services based on this knowledge.
3. I understand a $10 donation will be requested of me at each visit.
4. I certify that all information provided to the clinic is true and accurate. I understand that falsification of any information contained on this form will result in my inability to receive health care at the Physicians’ Care Clinic.
5. I certify that I do not have medical information of any kind.
6. I authorize the clinic pharmacy to dispense my medication(s) in their choice of container (which may not be child resistant). I accept responsibility for keeping my medications(s) in a safe place and out of the reach of children.
7. I give permission for PCC to (a) send my medical records to any physician to whom I may be referred to by PCC or (b) request records from any physician I have seen in the past.
8. I understand that I need to re-qualify annually or any time my circumstances change. I acknowledge that failure to provide the Physicians’ Care Clinic with an update on changes may result in my inability to receive health care.
9. I understand that if I miss a scheduled appointment (3) three times without giving the office a 24-hour notice, I will be subject to dismissal from the clinic.
10. I understand the participation in this clinic is entirely voluntary and may be discontinued at any time by myself or Physicians’ Care Clinic.
Please sign your signature below*

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Patient Application and Recertifications

Patient Contact Information

Patient Background Information

Patient Background Information Confirmation

Emergency Contact Information

Household Size and Income

Acknowledgement of Receipt of Privacy Notice

Patient Medical History

Medical Release Agreement

Patient Acknowledgment and Authorization for Treatment