Patient Registration and Consent

Patient Legal Name*

First NameLast Name

Patient's Date of Birth*

Is Patient 18 Years Old or Younger:

NoYes

Parent/Guardian Name

First NameLast Name

Parent/Guardian Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

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 Marital Status*

Patient's Maiden Name

Patient's or Guardian's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Does the patient have health insurance?*

Self-Pay Financial Responsibiltiy Agreement

I understand I am responsible for full payment of the County Health Department'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

Date

Insurance Financial Responsibility

I understand the County Health Department will submit my claim to my insurance if they are a participating provider for services, however, I understand that I am ultimately responsible for all payment obligations arising out of my treatment or care including, deductibles, co-payments, co-insurance amounts or any other patient responsibility indicated by my insurance. I understand that any amount deemed as the patient responsibility by my insurance company will be my financial responsibility and billed to me as such. Payment of unpaid services will be expected within 30 days of billed date, unless a payment plan has been put in place for said services.

If you are not familiar with your insurance coverage, NCHD/County Health Department recommends you contact your insurance carrier or plan provider directly. Your insurance company makes the final determination of your eligibility and benefits. If the patient/guardian disagrees with the determination made by their insurance carrier, the patient/guardian must contact the insurance company directly to appeal the decision.

Signature of Patient or Responsible Party

Date

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?

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.Format: (000) 000-0000.

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.

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

What is the reason for requesting an appointment?*

0/100

General Consent for Treatment

I hereby authorize the County Health Department 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.

Patient/Legal Guardian Signature*

Date*

Date

Consent for Telehealth Services

Telehealth consultations are not necessary for every visit, but may be necessary to complete an exam/visit.

1. PURPOSE: the purpose of this form is to obtain your consent to participate in a telehealth consultation in connection with the following procedure(s) and/or service(s): Medical Services and Mental Health Services via TELEHEALTH, including streaming video and audio feeds, with recording.

2. NATURE OF TELEHEALTH CONSULT: During the telehealth consultation:

a. Details of your medical history, examinations, x-rays, and test will be discussed with other health professionals through the use of interactive video, audio, and telecommunication technology.

b. A physical examination of you may take place.

c. A non-medical technician may be present in the telehealth studio to aid in the video transmission.

d. Video, audio and/or photo recordings may be taken of you during the procedure(s) or service(s).

3. MEDICAL INFORMATION & RECORDS: All existing laws regarding your access to medical information and copies of your medical records apply to this telehealth consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information for this telehealth interaction to researchers or other entities shall not occur without your consent. I understand that I have a right to access my personal information and copies of case records in accordance with Federal Law, Georgia Law and the GA Composite Board. I have read and understand the information provided above. I have discussed it with my provider, and all of my questions have been answered to my satisfaction.

4. CONFIDENTIALITY: The laws that protect the confidentiality of my personal information also apply to telehealth. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telehealth consultation, and all existing confidentiality protections under federal and Georgia state law apply to information disclosed during the telehealth consultation. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; expressed threat to harm or kill self; and where I make my mental or emotional state an issue in a legal proceeding.

5. RIGHTS: You may withhold or withdraw consent to the telehealth consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

6. RISKS: I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the provider that: the transmission of my personal information could be disrupted or distorted by technical failures; the transmission of my personal information could be interrupted by unauthorized persons; and/or the electronic storage of my personal information could be access by unauthorized persons.

a. In addition, I understand that telehealth-based services and care may not be as complete as face-to-face services. I also understand that if my provider believes I would be better served by another form of intervention (e.g. face-to-face services) I will be asked to make a face-to-face appointment or I will be referred to another health professional who can provide such services in my area.

b. I understand that there are potential risks and benefits associated with any form of telehealth services and that despite my efforts and the efforts of my provider, my condition may not improve, and in some cases may even get worse.

c. I understand that I may benefit from telehealth mental health services, but that results cannot be guaranteed or assured.

7. EMERGENCIES/CRISIS: By signing this document, I agree that certain situations including emergencies and crises are inappropriate for audio/video/computer based medical and/or mental health service.

a. If I am in crisis or in an emergency, I should immediately call: 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area. I understand that emergency situations include but are not limited to chest pain, shortness of breath or if I have thought about hurting or killing either another person or myself, if I have hallucinations, if I am in a life threatening or emergency situation of any kind, having uncontrollable emotional reactions, or if I am dysfunctional due to abusing alcohol or drugs.

b. I acknowledge I have been told that if I feel suicidal, I am to call 9-8-8 for immediate assistance.

8. CONSEQUENCES & BENEFITS: You have been advised of all the potential risks, consequences and benefits of telehealth. Your health care provider has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telehealth consultation. All your questions have been answered, and you understand the written information provided above.

I agree to participate in a telehealth consultation for the procedure(s) described above:*

Yes, I agree.No, I do not agree.

Patient/Legal Guardian Signature*

Date of Patient/Legal Guardian Signature*

Date

What is your relationship to the person signing above:*

Witness Signature

Date of Witness Signature

Date

Full Name of Witness:

First NameLast Name

Laboratory Services

I understand that some laboratory services are completed onsite and some are completed by an independent lab company at their facility. Charges for labs will be due at the time of your visit unless we are billing your insurance company. I also understand if I have insurance the County Health Department will provide my insurance information to the independent lab company for their billing purposes.

Signature of Patient/Guardian*

Date*

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 of Parent/Legal Guardian*

Date of Signature*

Date

Have you been referred for services by Houston County Board of Education?*

YesNo

Release of Medical Records

I authorize North Central District and/or Houston County Department of Health to release my medical records from this scheduled visit to Houston County School District, Student Support Services, 1100 Main Street, Perry, Georgia 31069, Phone: (478) 988-6200. I hereby authorize the release of all my medical, surgical and mental health records (Not including Psychotherapy Notes). This information is to include, but not limited to, billing and insurance information, patient demographics, medical information, mental health information, personal habits, alcohol use, drug use, and HIV status, if applicable. This authorization shall remain in effect until revoked by me in writing. A photocopy of this authorization shall be considered as effective and valid as the original. I understand that I have the right to receive a copy of this authorization. REASON FOR DISCLOSURE: Coordination of services with Houston County School District.

Signature of Parent/Legal Guardian

Date of Signature

Date

Media Release

By signing below, I grant permission for North Central Health District and 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 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

Date of Signature

Date