Patient Information

Patient Information
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Is this your legal name?*
If not, what is your legal name?

PrefixFirst NameMiddle NameLast NameSuffix
Marital Status*
Race*
Ethnicity*
Date of Birth*

MonthDayYear
Date
Age*
Gender*
Identify As*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Social Security Number*
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Employed*
Occupation
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Employer Phone Number
Please enter a valid phone number.
How did you hear about us?*
In Case of Emergency
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Relationship to Patient
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
The above information is true to the best of my knowledge
Signature*

Clear
Date*

MonthDayYear
Date

Appointment Policy
I, blanks* understand that as a patient of the HANDS clinic, it is my responsibility to keep my scheduled appointments. If I am unable to keep my appointment I will call to cancel and reschedule as soon as possible.
Signature*

Clear
Date*

MonthDayYear
Date

Appointment Reminders
This is a form to obtain your consent to receive appointment reminders and messages. Signing this form is voluntary. Whether or not you sign, the treatment you get from us will be the same.

Cost. Standard text message and minute usage rates from your mobile or Internet service provider may apply.

Risks. Sending and receiving text, email and voice messages frorn us may impact the privacy and security of your Personal Health Information ("PHI"}. Examples of PHI are: name, medical condition, or insurance coverage.
- Text, email and voice messages are not encrypted. Encryption makes sure your information stays safe. Information in text, email and voice messages may not be secure.
- If you share your phone, email, or your mobile phone is lost or stolen, someone other than us may be able to access your PHI. Messages can be read, used or shared by people other than us.
I, the Patient, understand and accept each of the following:
- I authorize HANDS of St. Lucie County to send me text, email and voice messages. This includes (but is not limited to) treatment-or care-related reminders.
- Text, email, and voice messages from HANDS of St. Lucie County may contain PHI. I will be responsible for information I share with HANDS of St. Lucie County.
- This consent will be in effect as long as I receive treatment from HANDS of St. Lucie County. I can ask HANDS of St. Lucie County for a more secure form of communication, like telephone.
- I will let HANDS of St. Lucie County know if my phone number changes. I can call (772) 462 5646 or send an email to info@handsofslc.org .
- I can cancel by signing a cancellation form.
- I have a right to receive a copy of this consent form for my records.
I have read the above information and by signing below I confirm*

Yes, I want to receive appointment remindersNo, I do not want to receive appointment reminders
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Release and Consent Form
I/We; the undersigned, hereby authorize you to release, without liability, information regarding my/our employment, income, and/or assets to the H.A.N.D.S. of St. Lucie County (Health Access. Network Delivery Systems), for the purpose of verifying information provided as part of the application for financial assistance.

I/We agree that a photocopy of this form may be used for the purpose stated above.

The original of this authorization is on file with the H.A.N.D.S. of St. Lucie County.
I/ We certify that the information provided in the Application and Income/Expense Certification is correct and may be verified as part of the review process. I understand· that the material representation of facts may result in prosecution to the fullest extent of the law.

Information may be requested from, but not limited to, the following groups or individuals: past and present employers, public assistance agencies, Veterans Administration, unemployment agencies, retirement systems, support and alimony providers, Social Security Administration, utility providers, insurance companies, financial institutions, physicians, hospitals, medical care providers and government.
Applicant Name*

First NameLast Name
Date*

MonthDayYear
Date
Social Security Number*
Signature*

Clear
Co-Applicant Name (if applicable)

First NameLast Name
Date

MonthDayYear
Date
Social Security Number
Signature

Clear
Signature Household Member 18 years or older (if applicable)

First NameLast Name
Date

MonthDayYear
Date
Social Security Number
Signature

Clear
Signature Household Member 18 years or older (if applicable)

First NameLast Name
Date

MonthDayYear
Date
Social Security Number
Signature

Clear
Signature Household Member 18 years or older (if applicable)

First NameLast Name
Date

MonthDayYear
Date
Social Security Number
Signature

Clear

Patient's Authorization to Release Medical Information
I understand that my family members, friends, and co-workers may ask questions about my medical condition over the telephone or in person. I also understand it is a breach of physician-patient confidentiality for my doctors to discuss my medical information any way with anyone without my expressed written consent. By signing this form I am designating the parties below with whom I wish HANDS of St. Lucie County to be able to discuss my medical condition.
In accordance with the above, I * , hereby authorize HANDS of Saint Lucie County to discuss with and release my medical information to the following individuals:
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
The below individuals are authorized to pick up any written prescriptionsm, medication samples, or x-ray films on my behalf:
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Furthermore, I understand that if there is any information in my medical record I do not want discussed with or released to the above, I must designate it here by stating what information is to be excluded.
Add any medical records to be excluded
Patient Name*

First NameLast Name
Date*

MonthDayYear
Date
Patient Signature*

Clear

ADDITIONAL INFORMATION
1) As noted on your HANDS referral form you may be referred to outside providers. Your referral and information will be faxed over to the volunteer provider, Please do not contact the provider yourself unless otherwise instructed to do so.

When the provider has agreed to provide services to you, either HANDS or the referring provider's office will contact you regarding an appointment date and time.

We appreciate the free services provided to HANDS patients and do our best to not burden offices with unnecessary calls. If you insist on contacting the referring provider's office without permission you may be placed on probation or discharged from the clinic.

2) As noted on your HANDS Clinic referral form you may be referred to outside providers at no cost to you, but you may be charged for further services incurred during the testing. You should not receive a bill from the hospital for outpatient testing, but you may receive a bill from the radiologist, pathologist, anesthesiologist, etc. These individuals do not have a sovereign immunity contract with HANDS Clinic and can bill you for services.

If you receive a bill please bring the original to the clinic. We will send a "Request for Charity Services Letter" to the provider asking that they write off or reduce the bill. It is at the individual provider's discretion to make changes to your bills. You will be responsible for these bills if the provider denies the charity request.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

Clear
First Appointment Scheduling*

It's ok to contact me by phone to schedule my first appointment.
Should be Empty:

Patient Information

In Case of Emergency

The above information is true to the best of my knowledge

Appointment Policy

Appointment Reminders

Release and Consent Form

Patient's Authorization to Release Medical Information

ADDITIONAL INFORMATION