Mid-Delta Health Systems, Inc

Mid-delta health systems, inc. /
Today's Date: / Registration Form / New Patient
Established Patient (Update Information)

Please select your preference of Primary Care Provider

(Please circle one)

Mid-delta health systems, inc. /

Dr. Curtis Schalchlin

Dr. Arpit Patel

Dr. Charles Feild

Dr. Pittman Moore

Courtney Moss, APN

Ashley Loftis, PA

Mid-delta health systems, inc. /

Please complete one registration form for each member in your household.

Patient’s Name: / Mailing Address:
Birth Date: / City:
Social Security Number: / State & Zip Code:
Male____ or Female____ / Home Phone Number:
Cell Phone Number:
Marital Status: Married____ Single____ Divorced____ Widowed_____ / Responsible Party (if patient is a minor):
Parent’s Name (if minor): / Are you employed? Yes or No
Employer’s Phone Number:
Student Status: Full Time______Part Time_____
Not a Student______/ Employment Status: Full Time____ Part Time___
Self Employed_____ Not Employed_____
Retired_____ Unknown______
E-MAIL ADDRESS: (ASK ABOUT OUR PATIENT PORTAL)
EMERGENCY CONTACT:
Name: Phone: Relationship:
Which pharmacy do you prefer?

THIS FACILITY PARTICIPATES IN THE PRESCRIPTION DRUG MONITORING PROGRAM. CLINICIANS IN THIS FACILITY WILL NOT PRESCRIBE NARCOTICS, BENZODIAZEPINES, OR CONTROLLED MEDICATIONS FOR CHRONIC USE.

Preferred Method of Contact
How would you like us to reach you? (Please circle all that apply) / What is the best time of day to reach you? (Please circle one)
Phone / Morning
Text / Afternoon
Email / Evening
What is your preferred language? / What type of reminders would like? (Please circle all that apply)
English / Appointment Reminders
Lab Results Reminders for Portal
Spanish / Health Maintenance Reminders
Prescription Confirmation
General Notifications
Only for Patients 18 and Older (Please circle answers below)
Ethnicity: / Are you homeless?
Hispanic / Yes
Non-Hispanic / No
Race (circle all that apply): / Do you have limited English?
American Indian/Alaska Native / Yes
Asian / No
Black/African American / Do you live in Government or Public Housing?
White/Caucasian / Yes
Unreported/Refused to Report / No
Are you a Veteran? / What is your sexual orientation?
Yes / Straight (heterosexual)
No / Lesbian/Gay (homosexual)
Are you a seasonal worker (someone who does not work all year)? / Bisexual
Something else______
Yes / I don't know
No / I choose not to disclose
Are you a migrant worker (someone who came here to work, then moves back home)? / What is your gender identity?
Male
Female
Yes / Transgender male/female
Transgender female/male
No / Other______
I choose not to disclose

Financial Policy and Contract

What kind of insurance do you have? (Circle all that apply)

MedicareMedicaidPrivate InsuranceMedicare Supplement

Workman’s CompNoneOther (Please List)______

Please give your insurance card(s) to the receptionist to copy for your chart.

MEDICAID OR ARKIDS:

If you or your child is enrolled in the Medicaid or ARKIDS program, this facility must be designated as your primary care physician. If we are not your primary care physician then you must have obtained a referral prior to being seen or the full amount will be due at the time of your visit.

SLIDING FEE SCALE:

You may qualify for our sliding fee scale program based on your total household income. There are four different levels for which you may qualify. You must furnish us with the appropriate proof of income, which may be one of the following:

W-2 forms or Income Tax Returns for the most current year will be valid until April 14th of the following year.

A Social Security benefit letter for the most current year will be valid until December 31, of the current year.

Check stubs (at least 2) will be valid for 6 months from the date of the check.

If you do not have proof of income with you at the time of your visit, you will be expected to provide us with proof of income within 48 hours of your visit. If you qualify for any of our levels, you will be requested to pay an initial fee of $15.00 at the time of check-in. Any remaining charges will be collected at the time of check-out.

□I would like to apply for the sliding fee scale by filling out the application for reduced fees.

SELF PAY:

If you do not have insurance and do not qualify for the Sliding Fee Scale, you will be requested to pay a set fee of $15.00 at the time of Check-In. Remaining charges will be collected at the time of check-out.

IF YOU ARE UNABLE TO PAY ANY OF THE ABOVE FEES AT THE TIME OF YOUR VISIT YOU WILL BE RESCHEDULED.

I have read and fully understand the financial contract as stated and agree to comply. I certify the above insurance information is correct. I hereby authorize treatment including whatever test or procedures may be directed by the provider. I authorize Mid-Delta Health Systems, Inc. to bill my insurance for services rendered and I also authorize the release of all medical information to my insurers. I understand that if neither insurance nor other benefits are available, I am responsible for the payment of this account. I authorize payment of medical benefits by my insurance to Mid-Delta Health Systems, Inc.

______

SignatureDate

______

Print NameRelationship if signing for a minor

Consent to Treatment/Confidentiality Authorization

Date:______Patient Name:______

Confidentiality is very important to us at Mid-Delta. Our standard policy is not to release any of your personal information unless you otherwise authorize below. Equally important is patient service and service to family and loved ones. Often family members inquire about health status or wish to be involved in the patient’s treatment. Sometimes specific conditions require that a family member or other loved one, help with your healthcare. You may provide a release of information that clarifies and allows us to discuss your healthcare with family or other loved ones. You may be selective in whom the information is given. By planning in advance,misunderstanding can be prevented. Feel free to discuss this with your healthcare provider.

Health Information Consent: I AUTHORIZE:

______Relationship:______

to give my Physician/Healthcare provider any and all information regarding any healthcare, personal observations and concerns and to receive any and all information from my Physician/Healthcare provider regarding my healthcare status, treatment plans and prognosis.

Release of information: I authorize the clinic to release medical information to third party insurance carriers for the purpose of filing claims, and to release or obtain medical information to/from providers of medical care and the Health Department for the purpose of continuity of care.
Consent to Care: I do hereby voluntarily consent to out-patient care at the Mid-Delta Health Clinic encompassing routine diagnostic procedures, examinations, and/or treatment by physicians, dentists, and/or other staff of the clinic.
Prescription History Consent: This consent form authorizes Mid-Delta Health Clinic to obtain and review my prescription history from pharmacies, other providers, and other third party entities such as insurance companies.
Effective Period: I understand that this consent/authorize will be valid and remain in effect as long as I attend the clinic or until I revoke this authorization.
The form has been fully explained to me and I have been given an opportunity to read the PATIENT BILL OF RIGHTS and PRIVACY POLICY. I understand the contents of these three documents.

______

Signature of Patient or GuardianRelationship to Patient

Reason patient is unable to give consent for self: ______

Application for Reduced Fees

It is necessary for us to ask personal questions in order to give you a discount on your medical/dental expenses. This information will be kept on file in our clinic in strict confidence. You must verify your income at least once every year. Proof of Household Income may include:

Your yearly income tax return and/or a copy of your W-2 form

2 current pay check stubs

A copy of your social security checks

Checks or documents or Other income you may receive

Your annual household income will be used to calculate the level of your discount.

Responsible Party Name:______Acct#______

Address:______City:______State:____Zip______

DOB:______SSN#_____-_____-______Telephone:______

*TOTAL number living in your household, include yourself:______

Marital Status(Circle One): Single Married Separated Divorced Widow(er)

*Is anyone in your household employed?Yes or No

List names of other members of household: ______

I declare the above information is true and I have given MDHS permission to investigate any information given in this application. I understand that this information will be kept in strict confidence. I also understand that if my income should change that I am required to notify the receptionist on my next visit.

□I refuse to provide my proof of income to apply for the reduced fees. In doing so, I agree that I will be responsible for the bill in full. (ONLY CHECK BOX IF YOU ARE NOT PROVIDING)

______

Responsible Party Signature Date Interviewer Signature

OFFICE USE ONLY

Weekly Gross Pay$______x4.334=

Bi-Weekly Gross Pay$______x2.167=

Twice Monthly Gross Pay$______x2.00=

Monthly Gross Pay$______x 12=

Totals x 12 Months

Total Annual Income: $______

Expiration Date: ______(1 year from today)

MID-DELTA HEALTH SYSTEMS

HEALTH HISTORY

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE STRICTLY CONFIDENTIAL AND WILL BECOME PART OF YOUR MEDICAL RECORD

NAME (Last, First, MI):______DOB:______Male/Female

Previous Primary Care Provider or ReferringProvider:______

Previous Specialist(s):______

PAST MEDICAL HISTORY (PLEASE CIRCLE ALL THAT APPLY)

Abnormal Mammo / Bipolar Disorder / Diabetes / Heart Murmur / Lupus
Abnormal Pap / Blood Disorder / Diverticulitis / Hepatitis / MI(Heart Attack)
Alcohol Abuse / Cancer(where) / Drug Abuse / High Blood Pressure / Prostate Disorder
Acid Reflux / Cataracts / DVT- Blood Clot / High Cholesterol / Renal Failure (Kidney)
ADHD / CHF Heart failure / Fibromyalgia / HIV / Seizure Disorder
Allergies / Crohns Disease / Glaucoma / Irritable Bowel Synd. / Stroke
Anxiety / Colon Polyp / Gout / Kidney Disease / Thyroid Disorder
Arthritis / COPD / Heart Disease / Liver Disease / Substance abuse: prescription drugs, street or illegal drugs

SURGERIES

YEAR / REASON / HOSPITAL

FAMILY HISTORY (Circle all that apply)

Father / Alive Deceased / Diabetes Hypertension Heart Disease Stroke
Depression Anxiety Mental disease Cancer
Mother / Alive Deceased / Diabetes Hypertension Heart Disease Stroke
Depression Anxiety Mental disease Cancer
Paternal Grandpa
(Father’s Side) / Alive Deceased / Diabetes Hypertension Heart Disease Stroke
Depression Anxiety Mental disease Cancer
Paternal Grandma
(Father’s Side) / Alive Deceased / Diabetes Hypertension Heart Disease Stroke
Depression Anxiety Mental disease Cancer
Maternal Grandpa
(Mother’s Side) / Alive Deceased / Diabetes Hypertension Heart Disease Stroke
Depression Anxiety Mental disease Cancer
Maternal Grandma
(Mother’s Side) / Alive Deceased / Diabetes Hypertension Heart Disease Stroke
Depression Anxiety Mental disease Cancer
Siblings
(brothers/sisters) / Alive Deceased / Diabetes Hypertension Heart Disease Stroke
Depression Anxiety Mental disease Cancer
Children / Alive Deceased / Diabetes Hypertension Heart Disease Stroke
Depression Anxiety Mental disease Cancer

SOCIAL HISTORY

Family/Household structure:

Have you applied and been denied public housing? Yes or No
Have you applied and been denied food stamps? Yes or No
Are you having problems with your landlord regarding safety issues? Yes or No
Have you applied and been denied for WIC, Medicaid, Disability or Social Security or SSI? Yes or No List:______
Whom does your support system consist of? (Who do you turn to when you need help) Circle all that apply: Mother, Father, Child, Sibling, Friend, Spouse, Other
Family /Household Structure (Circle One): Lives - Alone, with parent, with spouse, with other
Do you have legal guardian or health care proxy (someone who can legally make a decision for you if you are unable)? Yes or No If Yes, who______
Do you have a Primary care giver(the person who take care of you)? Yes or No If Yes, who______
Do you use drugs illegally?Yes or No
Did you have a drink containing alcohol in the past year?Yes or No
How many children do you have? ______
What is your occupation? ______
Do you have hazardous exposures in your occupation?Yes or No
Are you exposed to Agricultural chemicals?Yes or No
Do you exercise regularly?Yes or No
Do you consume caffeine on a daily basis?Yes or No
Have you traveled outside the US within the last 6 months?Yes or No

SEXUAL HISTORY

Are you sexually active? Yes or No

LIVING WILL

Do you have any advanced directives or living will? Yes or No

If no, are you interested in learning about advanced directives or living will? Yes or No

LEARNING NEEDS

Do you have problems with vision?Yes or No

Do you have problems with hearing?Yes or No

Do you have problems with reading?Yes or No