SOUTHWEST LOUISIANA PRIMARY HEALTH CARE CENTER, INC. dba EVANGELINE FAMILY MEDICINE ** NORTHSIDE COMMUNITY HEALTH CENTER ** ALL KIDS PEDIATRICS

SOUTHWEST LOUISIANA PRIMARY HEALTH CARE CENTER, INC DBA

EVANGELINE FAMILY MEDICINE ** NORTHSIDE COMMUNITY HEALTH CENTER ** ALL KIDS PEDIATRICS
PATIENT INFORMATION
NAME
AGE
DATE OF BIRTH

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number for patient.
Daytime Phone Number
Please enter a valid Daytime phone number for patient.
Cell Phone Number
Please enter a valid Cell phone number for patient.
SOC SEC NO
MARITAL STATUS

SINGLEMARRIEDDIVORCEDSEPARATEDWIDOWEDOTHER
EMPLOYMENT STATUS

EMPLOYEDSELF EMPLOYEDRETIREDUNEMPLOYED
GENDER

MALEFEMALELGBTQ
EMAIL ADDRESS
example@example.com
HOUSEHOLD MEMBERS
Member 1 Name
Enter first household member
Member 1 Age
Member 1 Income
Member 2 Name
Enter second household member
Member 2 Age
Member 2 Income
Member 3 Name
Enter third household member
Member 3 Age
Member 3 Income
Member 4 Name
Enter fourth household member
Member 4 Age
Member 4 Income
RESPONSIBLE PARTY/ GUARANTOR INFORMATION
Responsible Party Name
Relationship To Patient
Address

ADDRESS

Street Address Line 2

CITYSTATEZIP

Postal / Zip Code
Responsible Party Home Phone Number
Please enter a valid phone number.
Responsible Party Work Phone Number
Please enter a valid phone number.
Responsible Party Employer
IN CASE OF EMERGENCY - NOTIFY
Emergency Contact Name
Emergency Contact Phone Number
Emergency Contact Relationship
**REQUIRED -- ALL PATIENTS

(UNINSURED & INSURED MUST PRESENT PROOF OF HOUSEHOLD INCOME)
HOUSEHOLD INCOME
Daily
Weekly
Bi-Weekly
Monthly
Annually
NUMBER OF MEMBERS IN HOUSEHOLD
IF UNINSURED, ARE YOU INTERESTED IN APPLYING FOR INSURANCE?

YESNO
OFFICE USE ONLY
SLIDING FEE SCALE
NOMINAL
B
C
D
E
SELF PAY
INSURANCE INFORMATION
Medicare No.
Medicaid No.
Insurance Company
PPO
CO-PAY
NON-PPO
Insured Name On INS Card
Relationship To Patient
Insured ID No.
Insured Group No.
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS VALID AND CORRECT TO THE BEST OF MY KNOWLEDGE
SIGNATURE OF RESPONSIBLE PARTY*

Clear
DATE SIGNED

MonthDayYear
Date
I hereby request Southwest Louisiana Primary Health Care Center (SWLPHC) to provide me and/or my dependent with medical/dental/surgical care including but not limited to examinations, diagnostic test, and or other medical/dental/surgical procedure and treatment regimen, as they deem necessary. I agree that these services may be performed by a physician, dentist, nurse practitioner, physician assistant, or hygienist and agree to be examined and treated by a student training as a doctor, dentist, nurse practitioner physician assistant, or hygienist and who is supervised by a physician, dentist, nurse practitioner, physician assistant, or hygienist. I acknowledge my responsibility to pay for the care according to fees established by Southwest Louisiana Primary Health Care and I give my consent for such services. Furthermore, I authorize assignment of benefits for medical/dental services to be paid to Southwest Louisiana Primary Health Care.
AUTHORIZATION TO RELEASE INFORMATION:
I, First Name Last Name consent and authorize to the release of information to SWLPHC (Patient/Legal Guardian/Caregiver) regarding any/or any part of my medical record by any physician, hospital, or facility of which I have been a patient/client in accordance with patient privacy guidelines.
Name
Patient/Legal Guardian/Caregiver
Relationship
Patient/Legal Guardian/Caregiver
If Patient is a Minor

Complete this section
Name
Patient/Legal Guardian/Caregiver
Relationship
Patient/Legal Guardian/Caregiver
I, First Name Last Name hereby authorize that the release of any information (Parent/Legal Guardian/Caregiver) pertaining to the health of above-mentioned child/patient can be released to SWLPHC, all or part of patient's medical record by any physician, hospital, or facility of which said patient has been a client in accordance with patient privacy guidelines.
Name
Relationship
Name
Relationship
NAME OF PATIENT
SIGNATURE OF PATIENT OR GUARDIAN*

Clear
DATE

MonthDayYear
Date
PATIENT'S NAME
ADVANCED DIRECTIVES
"Terminal Condition" Declaration
My initials here indicate my desire to follow the "Terminal Condition" Declaration
"Permanently Unconscious" Declaration.
My initials here indicate my desire to follow the "Permanently Unconscious" Declaration.
CHOOSING A REPRESENTATIVE
I direct my attending physician to follow the instructions of the person named below as my Care Proxy to make medical treatment decisions on my behalf consistent with my wishes.
Care Proxy Name
Care Proxy Phone Number
Please enter a valid phone number.
Care Proxy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Name
Select Facility Phone & Address

Southwest Louisiana Primary Health Care Center, Inc8762 Hwy 182Opelousas, LA 70570 Medical: (337) 942-2005Evangeline Family Medicine Center505 E. Lincoln Rd. Ville Platte, LA 70586 Medical: (337) 363-0604Northside Community Health Center1800 Louisiana Ave.Lafayette, LA 70501 Medical: (337) 232-6787All Kids Pediatric of Opelousas920 N. Main StreetOpelousas, LA 70570 Medical: (337) 407-8697
Signature

Clear
Address
Witness Statement: Representative voluntarily signed this writing in my presence.

MonthDayYear
Signed Date
Witness Name
Witness Address
Witness 2 Name
Witness 2 Address
PATIENT'S RIGHTS
(Southwest Louisiana Primary Health Care Center, Evangeline Family Medicine, Northside Community Health Center and All Kids Pediatric)

SOUTHWEST LA PRIMARY HEALTH CARE CENTER, INC.

The patient has the right to reasonable and impartial access to care. The patient has the right to be treated with dignity and respect. The patient has the right to care that is considerate and respectful of his/her personal and ethical values and beliefs.

The patient has the right to formulate advanced directives and/or to appoint a surrogate to make health care decisions on his/her behalf to the extent permitted by law. The patient has the right to obtain from his/her provider complete and current information concerning his/her diagnosis, treatment, and prognosis. The patient has the right to personal privacy and confidentiality of information "within the limits of the law", including the right to be interviewed in privacy, and to discuss with the provider his/her care need for additional tests or referral. The patient has the right to accept or refuse treatment and to be informed of the medical consequences of such refusal.

The patient has the right to know (by name) the professionals responsible for the coordination of his/her care.

The patient has the right to a reasonable response to personal request/needs for treatment or service, within the facility's capacity and mission. The patient has the right to examine and receive an explanation of his/her bill regardless of the source of payment.

The patient has the right to make known any problems encountered during a visit to the health center and to obtain a grievance form from any staff person.
Name
Date

MonthDayYear
Date
PATIENT RESPONSIBILITIES
The patient has the responsibility to provide a complete and accurate medical history to the best of their knowledge, and provide information concerning complications or unexpected changes in their condition to his/her physician. The patient has the responsibility to participate in his/her plan of care when appropriate and provide complete and accurate information about his/her health. The patient has the responsibility to report perceived risks in their care and unexpected changes in his/her health.

The patient has the responsibility to comply with his/her physician's directions and the clinic staff's activities in order to carry out the practitioner's directions and to accept the consequences of his/her actions, if he/she refuses treatment or does not follow the practitioner's instructions.

The patient is responsible for asking questions when they do not understand what they have been told about their care and what they're expected to do.

The patient has the responsibility to follow clinic rules and regulations affecting patient care and conduct.

The patient has the responsibility to conduct himself/herself in a manner that is considerate of the rights of other patients, medical staff regarding privacy, quiet, and proper medical care.

The patient has the responsibility to respect the property of other people and Southwest La Primary Health Care Center. Any signs/actions of verbal abuse or physical threat to staff members or other patients will result in dismissal from the center.

The patient has the responsibility to receive prescriptions authorized by his/her provider. Patient must not make changes to their prescriptions for any reason. If this occurs, the patient will be dismissed from the center for violating this rule.

The patient has the responsibility to provide feedback about services, needs, and expectations.

The patient has the responsibility to meet any financial obligation agreed with the center.
PRIVACY POLICIES
NAME
Patient Date of Birth

MonthDayYear
Date
RESPONSIBLE PARTY
Household Member's Name 1
Household Member's 1 Age
Household Member's 1 Income
Household Member's 2 Name
Household Member's 2 Age
Household Member's 2 Income
Household Member's 3 Name
Household Member's 3 Age
Household Member's 3 Income
Household Member's 4 Name
Household Member's 4 Age
Household Member's 4 Income
** REQUIRED -- ALL PATIENTS
HOUSEHOLD INCOME DAILY

(UNINSURED and INSURED MUST PRESENT PROOF OF HOUSEHOLD INCOME)
DAILY
WEEKLY
BIWEEKLY
MONTHLY
ANNUAL
NUMBER OF MEMBERS IN HOUSEHOLD
NOMINAL A
D
E
F
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS VALID AND CORRECT TO THE BEST OF MY KNOWLEDGE
SIGNATURE OF RESPONSIBLE PARTY*

Clear
DATE

MonthDayYear
Date
I REFUSED TO RELEASED HOUSEHOLD INCOME TO SWLPHC INC
SIGNATURE

Clear
DATE

MonthDayYear
Date
WITNESS
Staff Initials
Should be Empty:

SOUTHWEST LOUISIANA PRIMARY HEALTH CARE CENTER, INC DBA

PATIENT INFORMATION

HOUSEHOLD MEMBERS

RESPONSIBLE PARTY/ GUARANTOR INFORMATION

IN CASE OF EMERGENCY - NOTIFY

**REQUIRED -- ALL PATIENTS

HOUSEHOLD INCOME

SLIDING FEE SCALE

INSURANCE INFORMATION

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS VALID AND CORRECT TO THE BEST OF MY KNOWLEDGE

AUTHORIZATION TO RELEASE INFORMATION:

If Patient is a Minor

ADVANCED DIRECTIVES

"Terminal Condition" Declaration

"Permanently Unconscious" Declaration.

CHOOSING A REPRESENTATIVE

PATIENT'S RIGHTS

PATIENT RESPONSIBILITIES

PRIVACY POLICIES

** REQUIRED -- ALL PATIENTS

HOUSEHOLD INCOME DAILY

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS VALID AND CORRECT TO THE BEST OF MY KNOWLEDGE