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  • Patient Registration Form

  • 1. BASIC INFORMATION

  • Date of Birth:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender Assigned at Birth:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Method of Contact:*
  • Patient Type*

  • 2. PARENT/GUARDIAN INFORMATION (If patient is minor)

  • Please notify Coplin Health Systems of any change in custody, guardianship, or authority to make healthcare decisions. Current court-issued or other legal documentation may be required to verify authority.
  • Format: (000) 000-0000.

  • Second Parent/Guardian

    Skip if documentation is not needed
  • Format: (000) 000-0000.
  • Patient lives with:

  • 3. RESPONSIBLE PARTY (Responsible for bill)

  • Responsible Party Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • 4. PROVIDER, PHARMACY, AND EMPLOYER INFORMATION

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 5. EMERGENCY/ALTERNATE CONTACT INFORMATION, PERMISSION TO SPEAK, AND TREAT

  • By providing an emergency/alternate contact, I understand that if I cannot be reached, Coplin Health Systems may communicate information reasonably necessary to address the patient's care.
    Psychiatric/mental health, substance abuse disorder and HIV/AIDS information will not be shared unless separately authorized or permitted by law.
    ** By checking the "Permission to Treat" box, I authorize the individual named below to accompany the listed patient for healthcare services and to consent to treatment on the patient's behalf, as necessary.

  • I, ______________________________________, authorize Coplin Health Systems to share personal health information with the named person(s) below. Please check the box to identify the information that is authorized to be shared with each named person.

  • Please fill all information below
    Rows
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  • 6. INSURANCE INFORMATION

  • PRIMARY INSURANCE:

  • Primary Insurance Policy Holder's Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • SECONDARY INSURANCE: (If applicable)

  • Secondary Insurance Policy Holder's Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • ** Coplin Health Systems is a Federally Qualified Health Center.
    ** No patient will be denied services due to an inability to pay.

  • 7. DENTAL INSURANCE INFORMATION

  • DENTAL INSURANCE:

  • Dental Insurance Policy Holder's Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • 8. Coplin Health Systems is a Federally Qualified Health Center, and we qualify for special pricing and discounted costs for our patients. To ensure that we continue to receive this designation and funding, we value gathering specific information about the population that we serve. We ask that you assist us by completing the following information:

  • How many people are currently living in your household? (Circle one)
  • What is your estimated household monthly net income? (Circle one)
  • Household Status:*
  • Military Status:*
  • Do you have a disability as identified by the Americans with Disabilities Act?
  • Race:
  • Ethnicity:
  • Sexual Orientation:
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  • 9. CURRENT MEDICATION AND HEALTH HISTORY

  • Medication:Dose(mg):Directions:

  • Medication:Dose(mg):Directions:

  • Medication:Dose(mg):Directions:

  • Medication:Dose(mg):Directions:

  • Medication:Dose(mg):Directions:

  • Special Consents

  • Permission to access my prescription history:*
  • Permission to record my visits temporarily for documentation accuracy; this may be declined during each visit:*
  • Permission for nursing and/or medical students to be present during the care:*
  • Patient Portal (Healow) Status:*

  • Telehealth Consent

    I understand that medical and behavioral health services may be provided through telehealth using audio and/or video technology. The provider may not be in the same room. I may refuse or stop telehealth participation at any time. If telehealth is not appropriate or technology is inadequate, I may need an in-person visit or other care, including emergency care when appropriate. I understand that technical difficulties or interruptions may occur. I will be informed of other people present with the provider, and they will participate only when needed to assist with care. I understand that providers must practice in accordance with applicable licensure requirements. I am responsible for applicable copays and coinsurance. The provider may request separate consent for photographs or recordings used for care or documentation. Any recording will be treated as protected health information and retained only temporarily as permitted by law and policy. Confidentiality protections apply, except where disclosure is required or permitted by law, including suspected abuse or neglect, threats of harm, and care coordination within Coplin Health Systems. This consent remains effective for one year unless revoked inwriting.

  • SCHEDULED APPOINTMENT CANCELLATION REQUIREMENTS ACKNOWLEDGEMENT

    Coplin Health Systems works to reduce missed appointments so that patients can receive timely medical, pediatric, dental, and behavioral health services. Automated reminders may be sent by telephone, text, or email. Patients should keep contact information current. Patients who need to cancel or reschedule should notify the office at least 24 hours before the appointment when possible. If the office is closed, a voicemail may be left. After two missed appointments without cancellation at least two hours before the visit, Coplin Health Systems may contact the patient to address barriers. After a third such missed appointment, the patient may be limited to available same-day appointments for 12 months beginning with the first missed appointment. The available provider may differ from the patient's primary care provider.

  • CONSENT FOR TREATMENT, AUTHORIZATION, AND FINANCIAL RESPONSIBILITY

    By signing below, I voluntarily consent for myself or the identified patient to receive routine evaluation and treatment from Coplin Health Systems. Services may include acute care, preventive care, screenings, diagnostic services, treatment, education, care coordination, dental services, and behavioral health services, as appropriate.I acknowledge that I received or was offered Coplin Health Systems' Notice of Privacy Practices. A copy is available from a Patient Representative, at Coplin locations, and at www.coplinhealth.com. The notice explains privacy rights and how health information may be used and disclosed for treatment, payment, healthcare operations, and other purposes permitted by law.I understand that Coplin Health Systems may participate in health information exchanges and electronic networks, including applicable West Virginia and Ohio health information networks, CommonWell, Carequality, and Surescripts. Information may be exchanged in accordance with applicable law, the Notice of Privacy Practices, network requirements, and available opt-out rights. I authorize Coplin Health Systems to submit claims and disclose information reasonably necessary to obtain payment from Medicare, Medicaid, CHIP, private insurers, benefit plans, and other responsible payors. I authorize benefits payable for Coplin Health Systems' services to be paid directly to Coplin Health Systems when permitted by the applicable plan. Verification ofinsurance does not guarantee payment.I accept responsibility for charges that are properly my responsibility under applicable law, payer requirements, Coplin Health Systems' contracts, and approved billing and sliding-fee policies. Coplin Health Systems offers a sliding-fee discount program based on income and household size. No patient will be denied healthcare services because of an inability to pay. Declining toprovide income or household information may prevent Coplin Health Systems from determining eligibility for a discount.I permit patient information to be used for claims processing, care coordination, audits, and other activities permitted by law. Coplin Health Systems may use the contact information provided for communications related to appointments, billing, and healthcare matters. I will protect the confidentiality of patient portal credentials.I certify that the information provided is accurate and agree to report changes to contact, insurance, custody, guardianship, or legal authority information. If I am signing for the patient, I certify that I am legally authorized to consent on the patient's behalf and will provide documentation when requested.This general consent remains effective for 12 months unless revoked earlier, updated, or superseded by a new consent. A different duration may apply to a specific service or authorization as required by law or Coplin Health Systems policy. Revocation does notaffect services already provided or actions already taken in reliance on this consent.

  • By signing below, I agree to permissions stated above.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • SCHOOL BASE HEALTH/MOBILE UNIT INFORMATION AND SERVICES

    **Complete all information below to enroll in School-Based Health, Portable Dental Unit, and/or Mobile Unit services.

  • Well Child Examination Consent

  • **Patient must not have received a Well-Child visit within the previous 12 months for this service to be covered by insurance. Insurance will not cover duplicate services within the same 12-month period.

  • Date of last Well-Child exam:
     - -
    2 digit month, 2 digit day, 4 digit year

  • PORTABLE DENTAL CONSENT

    Coplin Health Systems may use a portable dental unit at various locations to provide dental exams, minor dental procedures, fluoride treatments, cleanings and sealants. Services provided through the portable dental unit will be billed to insurance when applicable. Services utilized through the Portable Dental Unit will be billed to your insurance. If you do not have coverage, the sliding fee scale may provide a discount to be seen by the Dental Hygienist and/or Dentist. To see if you qualify for this reduced rate, you must complete the income section of the enrollment. **Patient MUST NOT have the same dental services within 6 months to qualify for insurance to cover service. **Insurances will not cover the fees for duplicate services.
  • Would you like to have any of the following services with our Portable Dental Unit?
  • Has a doctor told you to take antibiotics before dental treatment because of a joint replacement, heart problem or other health condition?
  • Date of Last Dental Exam
     - -
    2 digit month, 2 digit day, 4 digit year

  • Behavioral Health Services

    Coplin Health Systems offers confidential behavioral health services through the School-Based Health Program to help support students' emotional, behavioral, and mental well-being. Services are provided by licensed or qualified behavioral health professionals and are intended to promote healthy coping skills, emotional wellness, and academic success. Behavioral Health Services are not offered in every school, but a team member will reach out to you to establish services.
  • Please select from an option below

  • SCHOOL-BASED SUPPLEMENTAL AUTHORIZATION

    I authorize the student to receive services through Coplin Health Systems' school-based health program and/or mobile unit without the parent, legal guardian, or other authorized representative being physically present. Coplin Health Systems may attempt to contact the parent, legal guardian, or authorized representative before, during, or after a visit when clinically appropriate. Inability to make contact will not necessarily prevent services authorized by the general Consent for Services and this school-based authorization. I authorize Coplin Health Systems and the school nurse or designated school health official to exchange information reasonably necessary to coordinate the student's care and safety at school. This may include confirmation that the student was seen, attendance or return-to-school instructions, medication instructions relevant to the school day, activity restrictions, accommodations, and information needed to address an urgent health or safety concern. This authorization does not permit routine disclosure of the student's complete medical record. Specially protected information will be disclosed only when specifically authorized or otherwise permitted by law. This school-based authorization, including general consent remains effective until the student leaves or changes the school identified above, unless revoked in writing. Revocation does not affect services already provided or information already disclosed in reliance on this authorization.

  • By signing below, I agree with the school-based permissions stated above.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: