New Patient Enrollment Form

PATIENT AGREEMENT & PERMISSION TO TREAT
CommonGood Medical is a non-profit agency. To better serve you, we ask for your cooperation in following the policies listed below. These policies apply to both in-office and telehealth visits. If you are unable to follow these guidelines, or find them unacceptable, another care provider may be better able to meet your needs.
PLEASE READ AND INITIAL EACH STATEMENT TO ACKNOWLEDGE AGREEMENT
I understand that the examination and medical care given to me (or my minor child) will be provided by a licensed physician, physician assistant, or nurse practitioner
I understand that my medical records are available upon request by signing a medical records release form during clinic hours or through the Patient Portal.
I understand that CommonGood Medical does not prescribe narcotics.
I agree to complete the required annual re-enrollment process and provide my most current financial documents.
I understand that while CommonGood Medical will provide primary care needs, including necessary labs, at no cost, CommonGood Medical does not guarantee access to any care performed through outside services including imaging and specialty care. Furthermore, CommonGood Medical is not responsible for any costs incurred by my use of outside services.
I understand that I am solely responsible for the follow-through on testing and/or treatment ordered by medical providers at CommonGood Medical, and that if I fail to do so my treatment may be unsuccessful. I understand that I am expected to obtain any labs or imaging ordered by my physician prior to my next appointment.
All information is treated as confidential and will be held in strict confidence, except as required by the law or the following circumstances: (1) when there is a reasonable suspicion of child abuse, whether the patient is the victim or the abuser, or when there is a threat of harm to a third party; (2) when there is a threat of self-inflicted harm; (3) when there is a reasonable suspicion of intimate partner violence; (4) when there is a threat against the clinic itself.
I understand that if I miss three (3) appointments in one year, without calling or texting to cancel more than 24 hours in advance, I may not remain a CommonGood Medical patient. I understand that I may leave a voicemail or reply in the confirmation text to cancel. I understand that if I am more than five (5) minutes late for my appointment, I am not guaranteed to be seen and may have to be rescheduled and that it will be considered a no-show.
I agree to inform CommonGood Medical within 30 days of any change in my name, address, telephone number, household income, or if I have qualified for insurance of any kind by calling (469) 712-4246.
I authorize any health care professional associated with CommonGood Medical to disclose any personal, evaluation, and/or treatment information to other health care professionals for continuation of care or for purposes of obtaining health care information from other facilities when medically necessary.
I understand that if I no-show an in-clinic specialty appointment (any non-primary care), I will not be eligible to reschedule within the calendar year.
I understand that if I am uncooperative, verbally or physically abusive, intoxicated, or behave in an inappropriate manner, I may not be eligible for services at CommonGood Medical.
I understand that if I no-show an outside specialty appointment two (2) times in one year, without providing the specialty office appropriate notice as determined by that office, I will not remain a CommonGood Medical patient.
I understand that video- or audio-taping of any portion of my visit, by any method or device, including cell phones, is strictly prohibited. I understand that CommonGood Medical and its representatives (paid or volunteer) do not consent to having any conversations recorded.
If I am referred to another agency for assistance, I give my permission for pertinent information to be released to that agency. If CommonGood Medical provides me with referrals, I agree there is no legal responsibility for services provided by other agencies.
I understand that if I no longer meet the qualifications to be a CommonGood Medical patient, I may schedule a final "graduation appointment" within 30 days of dismissal from practice in order to receive a one-time refill on any medications as determined by my provider. If I cancel or no-show the appointment, I may not reschedule.
I have read, understand, and agree to the guidelines set forth by CommonGood Medical. I understand that I can be denied further services provided CommonGood Medical if I have given false or misleading information.
Patient Signature
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Signature of Parent/Legal Guardian (if applicable):

NOTICE OF PRIVACY PRACTICES

A laminated copy of CommonGood Medical's Notice of Privacy Practices may be found at any time at the front desk.
I, First Name* Last Name* , have read and understand CommonGoodMedical’s Notice of Privacy Practices. I understand that if I have any questions, I may contact CommonGood Medical’s Director of Operations, who is acting as the Privacy Official, at (469)-712-4246. I understand that I may receive a copy of these notices if I request one.
Patient Record Sharing Permissions:
By initialing here, Signature* I consent to and understand that CommonGoodMedical’s EMR system will automatically exchange my medical records with any providers who care for me as a patient. The duration of this consent is indefinite unless otherwise revoked in writing.
Patient Name
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MonthDayYear
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Patient Signature
Parent/Legal Guardian Signature (if applicable)
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Free Clinic Federal Tort Claims Act (FTCA) Patient Notice of Limited Liability
To be provided to the individual patient before health care services are provided, except in emergency cases when notice may be provided as soon after the emergency as is practical, or to a parent or guardian when the patient lacks legal responsibility for his/her are under state law.
Notice to Patients
This is to notify you that under Federal law relating to the operation of free clinics, the Federal Tort Claims Act (FTCA), (See 28 U.S.C. §§ 1346(b), 2401(b), 2671-80) provides the exclusive remedy for damage from personal injury, including death, resulting from the performance of medical, surgical, dental, or related functions by any free clinic volunteer health care practitioner who the department of Health and Human Services has deemed to be an employee of the Public Health Service. This FTCA medical malpractice coverage applies to deemed free clinic volunteer healthcare practitioners who have provided a regular or authorized service under Title XIX of the Social Security Act. The legal liability of the deemed individual is limited pursuant to section 224(o) of the Public Health Service Act, 42 U.S.C. 233(o).

(i.e.: Medicaid program) at a free clinic site or through offsite programs or events carried out by a free clinic (See 42 U.S.C. § 233(a), (o)).

The above federal law may cover certain free clinic healthcare professionals providing health care services to patients at this free clinic.
CONSENT FOR CHARITY CARE
I, First Name* Last Name* acknowledge that the physicians of CommonGood Medical are volunteer health care providers and are not administering care for or in expectation of compensation. I also understand that as volunteer health care providers, these physicians are immune from civil liability for any act or omission resulting in death, damage, or injury, as long as the volunteers act in good faith and in the scope of his or her duties within the organization in providing the health care services.

Furthermore, I realize that the civil liabilities of both the charitable organization and an employee of the charitable organization are limited to money. These limits apply to the employee and the organization separately; they are not aggregate limits.
Patient Signature
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MonthDayYear
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Patient Name
Parent/Legal Guardian Signature (if applicable)

Communication of Health Information
Communication with Patient

Please choose ONE of the following for each method of communication:
Cell Phone:
Home Phone:
Communication with Others

I hereby give permission to the staff of CommonGood Medical to disclose and discuss any information related to my medical condition(s) with the following family member(s), other relative(s), and/or close personal friends:
First Name Last Name Relationship Phone Number
First Name Last Name Relationship Phone Number
First Name Last Name Relationship Phone Number
'X' if applicable I do not wish to disclose any information with anyone.
The duration of this authorization is indefinite unless otherwise revoked in writing. I understand that requests for medical information from persons not listed above will require my specific authorization prior to the disclosure of medical information.
Patient Signature
Date

MonthDayYear
Date
Parent/Legal Guardian Signature (if applicable)

Patient Rights and Responsibilities
At CommonGood Medical we believe in team-based health care. That means that we, as health care providers, have an active role, and you, as a patient, have an active role.

CommonGood Medical is responsible for:

- Providing evidence-based primary care services.

- Providing considerate and respectful care.

- Explaining all procedures and test results at patient appointments.

- Providing reasonable answers to questions at appointments.

- Keeping all medical information private.

You, as a patient, are responsible for:

- Being on time for appointments. If you must cancel or reschedule, you must call us at (469) 712- 4246 at least 24 hours prior to the appointment time. Leaving a voicemail will constitute contact.

- If you miss three appointments in one year without calling to cancel or reschedule, CommonGood Medical may discontinue care.

- As you are able, making a donation of any amount at each visit to help cover the costs associated with the care provided to the next patient.

- Obtaining any lab testing or imaging that is ordered by your physician prior to your next appointment.

- Informing CommonGood Medical within 30 days of any change in your insurance status, income, or contact information. Failure to do so can result in delayed treatment.

- Timely providing updated patient enrollment documents (proof of residency and income) each year.

- Being an active partner in managing your health.
Patient Name
Patient Signature
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New Patient Enrollment Packet

PATIENT AGREEMENT & PERMISSION TO TREAT

PLEASE READ AND INITIAL EACH STATEMENT TO ACKNOWLEDGE AGREEMENT

NOTICE OF PRIVACY PRACTICES

Patient Record Sharing Permissions:

SOCIAL DETERMINANTS OF HEALTH SCREENING

FOOD

HOUSING/UTILITIES

TRANSPORTATION

INTERPERSONAL SAFETY

Free Clinic Federal Tort Claims Act (FTCA) Patient Notice of Limited Liability

Notice to Patients

CONSENT FOR CHARITY CARE

Communication of Health Information

Communication with Patient

Communication with Others

Patient Rights and Responsibilities