I authorize Healing Hands Health Center to release my healthcare information to the person(s) listed below. I understand that the person(s) named on this authorization will be given access to obtain results/information on my behalf. I authorize the person(s) indicated to pick-up materials pertinent to my
medical care.

To provide you with the quality care you deserve, we ask that you do your part by agreeing to the following clinic guidelines.

Patient Care:

• Various volunteer physicians, dentists, specialists, nurses, dental assistants, medical assistants, hygienists, and students in training will be providing your care.
• Pre-doctoral or pre-hygienist clinic treatment is performed by student doctors and student hygienists under the direct supervision of an experienced University of Tennessee faculty dentist and ETSU faculty
  physician or hygienist.
• Treating any provider with disrespect will result in an immediate dismissal from the program.

Appointment Policy:

• It is your responsibility to provide our clinic with a working phone number and to update us with anynew telephone numbers.
• If we cannot reach you to confirm your appointment and you do not call 24 hours prior to your appointment to confirm, your appointment will be given to the next deserving patient in need, and you will be responsible for the no show/missed appointment fee.
• Two missed appointments within a 6-month period will result in temporary dismissal from the clinic. After two missed appointments, you will receive a dismissal letter and will not be allowed to schedule a visit for 6 months. After that you may call for an appointment pending our capacity.
• Please understand that our clinic is facing long wait lists as many in our community need quality affordable healthcare. As such, and while we will always try to accommodate our patients the best we can, a missed appointment means a missed opportunity for care for another neighbor in
  need.
• Please refer to our complete no-show policy.

Patient Responsibilities:

• I understand that if I am a medical patient who needs medication assistance or Project Access, I may be asked to provide more information.
• I understand that I am responsible for any bills that may result from referrals to specialists or visits to the emergency room, urgent care, etc. I authorize Healing Hands Health to release the necessary medical records needed for any referral.
• I understand that if I give false information to any representative of Healing Hands Health, I will be dismissed from the clinic.
• We understand that having a health/dental issue is stressful, but all staff and volunteers are to be treated with respect, in person and phone calls.  Failure to do so will result in your dismissal from the clinic; this includes, but not limited to foul language, threats, shouting, etc.
• Healing Hands does not provide narcotic pain management. We do not keep narcotics on the premises.
• I agree to update my income documentation every year.
• I agree to update my address and phone number when it changes.
• You must advise the staff if you have any dental or medical insurance.
• Arrive on time to your appointments. Arriving 15 minutes or more late for your appointment may result in your appointment being rescheduled. As a courtesy, you may receive a reminder call, but not always. It depends on our staffing and the volume of patients. It is your responsibility to keep track of your appointments.
• Give a 24-hour notice for cancelling appointments. Failure to do so will result in the no-show policy being enforced. 
• The value for a standard patient visit to serve your healthcare needs is $140. We charge our patients a small fee so we can continue to meet the expanding needs of our community. I understand that the following patient fees are due at the time of my visit:

             Medical $25
             Eyeglasses $25
             Dental $50
             Other Dental Procedures $100
             Eye Exam $20
             Dental Hygiene $25
             Medication Admin Fee $5/medication ($35 cap/visit)

Release:

• I give permission for my photo, interview, and/or comments to be used for marketing and fundraising purposes.
• I give permission for my x-rays or photos to be sent to other agencies associated with Healing Hands and/or to private doctors.

I certify that I have completely read the clinic guidelines above. I understand each statement and agree to follow these guidelines.

No Show Policy/Missed Appointment Policy

Late arrival policy:
To allow our team to provide you with care in the best possible conditions, we ask our patients to arrive on time for their appointments. Should you arrive more than 15 minutes late for your visit, you will have to reschedule, and this will count as a missed appointment.

Rescheduling/canceling your appointment:
Healing Hands Health patients are welcome to reschedule/cancel their appointments up to 24-hours prior. After that, rescheduling will count as a short cancellation/missed appointment.

We will attempt to contact you by phone to remind you of your appointment. It is your responsibility to make sure that the phone number you provided to our clinic is a working number and that your cell phone has minutes available. If your phone number changes prior to your appointment time, it is your responsibility to contact Healing Hands Health and provide us with
your new telephone number.

Missed appointments and dismissals:
An appointment is considered missed when:
• A patient asks to reschedule an appointment giving us less than 24-hr notice
• A patient does not show up to an appointment
• A patient shows up more than 15 min late to an appointment
• A patient arrives unprepared for an appointment (failure to take premedication, and/or patient comes to appointment with an unsupervised child. Please make childcare arrangements prior to your appointment)

Two missed appointments within a 6-month period will result in temporary dismissal from the clinic. After two missed appointments, you will receive a dismissal letter and will not be allowed to schedule a visit for 6 months. After that you may call for an appointment pending our capacity.

Please understand that our clinic is facing long wait lists as many in our community need quality affordable healthcare. As such, and while we will always try to accommodate our patients the best we can, a missed appointment means a missed opportunity for care for another neighbor in need.

Healing Hands Health thrives to provide quality, professional and compassionate care to all patients. Respect, empathy and active listening are the cornerstones of our mission. Patients displaying disrespectful, rude, racist, discriminatory, threatening, or aggressive behavior/language toward any member of the HHH staff will be immediately dismissed from the clinic with no possibility to establish care again.