Lindsey Support Center Telehealth Consent

Lindsey Student Support Center Tele Health Clinic

Patient Registration Form
Patient Legal Name*

Last NameFirst Name
Patient's Date of Birth*

MonthDayYear
If patient is 18 years or younger:
Parent/Guardian Name

Last NameFirst Name
Parent/Guardian Phone Number
Please enter a valid phone number.
Patient's Preferred Language:*
Patient's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient's Race*
Patient's Ethnicity*
Patient's Gender at Birth*
Patient's Gender Identification Now*
Patient's or Guardian's Phone Number*
Please enter a valid phone number.
Does the patient have health insurance?*
If the patient has NO health insurance:

Read and sign the Self-Pay Financial Responsibility Agreement
Self-Pay Financial Responsibiltiy Agreement

I understand I am responsible for full payment of the County Health Deparment's scheduled fees at the time of services unless I qualify for special discounted fees. Certain programs offer assistance or a payment plan for said services. Discounted fees are based on my personal and/or household's income (with proof of income) and number of dependents, which I have provided truthfully and accurately to the County Health Department staff. I also certify that I have notified the County Health Department staff if any income or insurance information has changed since my last visit.
Signature of Patient or Responsible Party

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If YES, the patient has health insurance:

Complete the questions below.
What is the name of the health insurance provider?
:
What is the name of the insurance policy holder?
Type the first and last name.
How is the policy holder related to the patient?
What is the birth date of the policy holder?

MonthDayYear
Date
What is the gender of the policy holder?
What is the address of the insurance policy holder?

Street Address

Street Address Line 2

CityState

Zip Code
What is the insurance policy holder's phone number?
Please enter a valid phone number.
What is the Member ID Number/Subscriber Number?
What is the Group Number?
Attach a photo or scanned copy of the FRONT of the health insurance card.

Cancelof
Attach a photo or scanned copy of the BACK of the health insurance card.

Cancelof
What is the reason for requesting an appointment?*

0/20
General Consent for Treatment

I hereby authorize the County Health Dpartment to render the appropriate services and presumptive treatment at my request. I understand that to render care, the staff may need to examine me, conduct tests or diagnositc procedures, administer medicines or treatments. I understand that I will have an opportunity to ask my healthcare provider questions regarding such care and read any informational materials given to me as deemed appropriate. I acknowledge that all of the information I have provided to the County Health Department staff is true and accurate to the best of my knowledge.
Signature*

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Date*

MonthDayYear
Date
North Central Health District Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I have reviewed and understand the Notice of Privacy Practices for the North Central Health District. The Notice sets forth the ways in which my personal health information may be used or disclosed by the North Central Health District or the County Health Department and outlines my rights with respect to such information.
Signature*

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Media Release

By signing below, I grant permission for North Central Health District and/or Houston County School District to use their photographs in publications, both print and digital forms, including the companies' websites, newsletters, emails, social media posts, videos, brochures, and advertisements. In giving this consent, I release North Central Health District and/or Houston County School District and all third parties from liability for any violation of my personal or proprietary right that either may have in connection with the reproduction or use of their photographs or videos.
Signature

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Lindsey Student Support Center Tele Health Clinic

If patient is 18 years or younger:

If the patient has NO health insurance:

If YES, the patient has health insurance:

Media Release