Patient ID #:______

Patient Information(Please complete all fields)

First Name______Parent or Guardian (if under 18):
Middle Name______Name______
Last Name______Phone # ______
Address______Date of Birth______SSN#______

City______State______Relationship to patient______

Zip______
Authorized to leave a voicemail if necessary?Yes NoPharmacy Information

Preferred Contact NumbersPreferred Pharmacy ______

Home Phone #______Pharmacy Address______

Cell Phone # ______

Work Phone #______Emergency Contact Information

Preferred Email:______Name ______

Soc Sec #______Address ______

Birth Date______/ ______/ ______Phone #______
(Month) (day) (year)
Marital StatusSingle Married Divorced OtherRelationship to Patient ______

Keep Visits Confidential from Emerg. Contact? Yes NO

Ethnicity Hispanic Non-Hispanic

Race Black/African American Hispanic Caucasian AsianMore than one Race Other

Language English Spanish Nepali Swahili Other

Gender Identification Male Female Transgender Male/Female to Male Transgender Female/Male to Female

Other Chose not to disclose

Sexual Orientation Lesbian or Gay Straight(not Lesbian or Gay Bisexual Chose not to disclose Don’t know, or please check Something else

How did you hear about Shawnee Christian Healthcare Center?
Word of Mouth Flyer Website Another Facility/Physician Referral Service Radio
Patient (Name: ______) Physician Yellow Pages Facebook Internet Search Other

Patient Status:
Occupation: ______Full-time Part-time Student

Place of Employment: ______

What is your Veteran Status?VeteranNon-Veteran

What is your citizenship status? US Citizen by Birth Immigrant Permanent Resident/Alien
RefugeeNaturalized Citizen Student Visa Other

Where have you received Prior Medical Care?

Primary Care ProviderHospital Urgent CareNeighborhood Clinic

Do you work on a farm? YesNoRetired Farm Worker
If so, are you: Employed year-roundMigrant Seasonal

Do you need an Interpreter for your visits?YesNo

What are your living arrangements?Not homeless Homeless (start date: ______)

Street Homeless Shelter TransitionalDoubling UpUnknownOther

Family Income Level:

Please circle your range of YEARLY income next to your family (AKA household) size line in the following chart:

By Providing your income Level you will help our clinic receive grant funding.

Family Size / Class 1
0-100 % / Class 2
101-125 % / Class 3
126-150 % / Class 4
151-175 % / Class 5
176-200 % / Class 6
200+ %
1 / $0-$12,060 / $12,061-$15,075 / $15,076-$18,090 / $18,091-$21,105 / $21,106-$24,120 / $24,120+
2 / $0-$16,240 / $16,241-$20,300 / $20,301-$24,360 / $24,631-$28,420 / $28,421-$32,480 / $32,480+
3 / $0-$20,420 / $20,421-$25,525 / $25,526-$30,630 / $30,901-$35,735 / $35,736-$40,840 / $40,840+
4 / $0-$24,600 / $24,601-$30,750 / $30,751-$36,900 / $36,901-$43,050 / $43,051-$49,200 / $49,200+
5 / $0-$28,780 / $28,781-$35,975 / $35,976-$43,170 / $43,171-$50,365 / $50,366-$57,560 / $57,560+
6 / $0-$32,960 / $32,961-$41,200 / $41,201-$49,440 / $49,441-$57,680 / $57,681-$65,920 / $65,920+
7 / $0-$37,140 / $37,141-$46,425 / $46,426-$55,710 / $55,711-$64,995 / $64,996-$74,280 / $74,280+
8 / $0-$41,320 / $41,321-$51,650 / $51,651-$61,980 / $61,981-$72,310 / $72,311-$82,640 / $82,640+

*Family units of more than eight members, add $4,160 for each additional member (Above 200% = no discount)
A sliding fee is offered to uninsured/underinsured patients. All payers are accepted. To apply for the sliding fee option, patients should bring income documentation:

  • Previous year’s W2 form or tax return form
  • Current paycheck stubs (at least 2)
  • Letter from employer (must be written on company letterhead)
  • If self-employed, a Form 1040 tax return from previous calendar year
  • If state income – letter from social worker, copy of award letter from the SSA, check stub or letter with details of pension benefits

The poverty guidelines updated periodically in the Federal Register by the US Department of Health and Human Services under the authority of 42 U.S.C. 9902(2).

Shawnee Christian Healthcare Center

234 Amy Avenue

Louisville, KY 40212

502-778-0001

Notice of HIPPA Privacy Practices

Privacy consent for Use or Disclosure of Patient Information for the Purposes of Treatment, Payment and Healthcare Operations

I hereby consent to Shawnee Christian Healthcare Center using or disclosing my protected health information for the purpose of providing treatment to me, obtaining payment for healthcare services rendered to me or to carry out the Practice’s healthcare operations. I also consent to Shawnee Christian Healthcare Center using or disclosing my protected health information for treatment activities provided by another healthcare provider, as well as the payment activities conducted by another healthcare provider or entity. I further consent to the disclosure of my protected health information in order for another provider or healthcare entity to conduct healthcare operations including quality assessment and reviewing the competence of healthcare professionals.

Specific Records Expressly Include

I expressly authorize release of information for the purpose of treatment and healthcare operations if it is part of my protected health information. By signing this form, I acknowledge that this includes any and all information including:

  • Chemical Dependency/ Substance Abuse
  • Drugs
  • Alcohol
  • Sexually Transmitted Diseases

I further acknowledge Shawnee Christian Healthcare Center has provided me a copy of its Notice of Privacy Practices, which provides a detailed description of the uses and disclosures allowed by this consent, as well as other rights I have regarding my

X

Signature of Patient or Personal Representative Date

Print Name of Patient or Personal Representative

Description of Personal Representative’s Authority

Permission for Full Disclosure of Protected Health Information
Please list someone else that we can discuss your health information with if necessary.
(This includes any or all health information)

Name ______Phone #______

Relationship to Patient ______Authorized to Make Medical Decisions?
YesNo

COMPLETE THIS SECTION IF YOU HAVE INSURANCE (MEDICARE, MEDICAID, OR OTHER)

Name of Company ______Effective Date ______

Insured Person’s Name ______Insured Peron’s DOB ______

Insured Person’s SSN ______Patient Relationship to Insured Person ______

Member ID number ______Group Number ______

Secondary Insurance

Name of Company ______Effective Date ______

Insured Person’s Name ______Insured Peron’s DOB ______

Member ID number ______Patient Relationship to Insured Person ______

Assignment and Release

I hereby consent to all treatment deemed necessary by the medical staff of Shawnee Christian Healthcare Center. I authorize the release of any information necessary to process this claim. I request that any money due me for medical benefits be assigned to Shawnee Christian Healthcare Center, and I realize that I am responsible for any and all differences. I have received the HIPAA Notice of Privacy Practices and agree to its terms. I agree to pay my fee at the time of service, in accordance with Shawnee Christian Healthcare Center policies. I grant permission for third party auditors to view private health information as a part of the evaluation process. I further attest that, as of the date of my signature, the income sources listed constitute all of my household income, and that the family members listed are all solely dependent on that income, or that the explanation provided to verify my income level is truthful. All information on this form is truthful to the best of my knowledge and if there are changes to my income, insurance status, or other information I will inform Shawnee Christian Healthcare.

Patient/Guardian Signature X______Date______

Relationship to Patient X______

____ (Initial) -- I have received the Shawnee Christian Healthcare Policy Document and understand the terms, including my responsibilities as an SCHC parent/ guarantor. Should I have questions, it is my responsibility to inquire of the SCHC staff.

I have read and agree with the Patient Rights and Responsibilities.

X______

Printed NameSignatureDate

1

SCHC Patient Information