Prevention Fast-Track ☐

REGISTRATION FORM

Welcome to Affinity Health Center! We are happy you have chosen us for your care. To register, please complete this form. Several of the items below help us ensure that we are meeting the needs of the population we serve, so please be as thorough
as you can. Let us know if you have any questions or if you need help completing this form.

WHAT SERVICES ARE YOU SEEKING? Check all that apply

Primary Medical Care Mental Health Counseling Dental

HIV Medical Care Case Management Nutrition

PATIENT INFORMATION

Date of Birth: / Month / Day / Year / Social Security Number
-  -
Legal Name:
First / Middle Initial / Last

Name you would like to be called, if different from legal name: ______

Street Address / Apartment #
City / State / Zip Code / County

Affinity Health Center will send you mail at this address. We believe it is important for us to communicate with you regarding services, payments, etc.

Primary Phone number ______Type: ¨ Home ¨ Mobile/Cell ¨ Work/Business ¨Friend/Relative
OK to text: ¨Yes ¨No
Secondary Phone number ______Type: ¨ Home ¨ Mobile/Cell ¨ Work/Business ¨Friend/Relative
OK to text: ¨Yes ¨No
Other Phone number ______Type: ¨ Home ¨ Mobile/Cell ¨ Work/Business ¨Friend/Relative
OK to text: ¨Yes ¨No

Guarantor of Patient:

☐ Self ☐ Parent: ______

☐ Other: ______

To comply with our Federal grants, we report demographic information collected (aggregated) from all of our patients.

What is your annual income? ______Head of Household? Self Other: ______

Please check one of the following boxes that best matches your total FAMILY income:

Fee / Family Size 1 / Family Size 2 / Family Size 3 / Family Size 4
$5.00 / No income to $990.00 monthly
(0-11,880 annually) / No income to $1,335.00 monthly
(0-16,020 annually) / No income to $1,680.00 monthly
(0 – 20,160 annually) / No income to $2,025.00 monthly
(0 - 24,300 annually)
$10.00 / $990.08 - 1,237.50 monthly
(11,881 - 14,850 annually) / $1,335.08 - 1,668.75 monthly
(16,021 – 20,025 annually) / $1,680.08- 2,100.00 monthly
(20,161 – 25,200 annually) / $2,025.08 – 2,531.25 monthly
(24,301- 30,375 annually)
$15.00 / $1,237.58 – 1,485.00 monthly
(14,851 - 17,820 annually) / $1,668.83 – 2,002.50 monthly
(20,026 – 24,030 annually) / $2,100.08 - 2,940.00 monthly
(25,201 – 30,240 annually) / $2,531.33 - 3,037.50 monthly
(30,376 - 36,450 annually)
$30.00 / $1,485.08 - 1,732.50 monthly
(17,821 – 20,790 annually) / $2,002.58 - 2,336.25 monthly
(24,031 – 28,035 annually) / $2,520.08 - 2,929 monthly
(30,241 – 35,280 annually) / $3,037.58 - 3,543.75 monthly
(36,451 - 42,525 annually)
$45.00 / $1,732.58 – 1,980.00 monthly
(20,791 - 23,760 annually) / $2,336.33 - 2,670.00 monthly
(28,036 – 32,040 annually / $2,940.08 - 3,360.00 monthly
(35,281 - 40,320 annually) / $3,543.83 - 4,050.00 monthly
(42,526 - 48,600 annually)
Pay at 100% / $1,980.08 or more monthly
(23,761 or more annually) / $2,670.08 or more monthly
(32,041 or more annually) / $3,360.08 or more monthly
(40,321 or more annually) / $4,042 or more monthly
(48,601 or more annually)
Fee / Family Size 5 / Family Size 6 / Family Size 7 / Family Size 8
$5.00 / No income to $2,370.00 monthly
(0 - 28,440 annually) / No income to $2,715.00 monthly
(0 - 32,580 annually) / No income to $3,060.83 monthly
(0 - 36,730 annually) / No income to $3,407.50 monthly
(0 - 40,890 annually)
$10.00 / $2,370.08 - 2,962.50 monthly
(28,441 - 35,550 annually) / $2,715.08 - 3,393.75 monthly
(32,581 - 40,725 annually) / $3,060.92 - 3,826.04 monthly
(36,731 - 45,913 annually) / $3,407.58 - 4,259.38 monthly
(40,891 - 51,113 annually)
$15.00 / $2,962.58 - 3,555.00 monthly
(35,551 - 42,660 annually) / $3,393.83 - 4,072.50 monthly
(40,726 - 48,870 annually) / $3,826.13 - 4,591.25 monthly
(45,914 - 55,095 annually) / $4,259.46 - 5,111.25 monthly
(51,114 - 61,335 annually)
$30.00 / $3,555.08 - 4,147.50 monthly
(42,661 - 49,770 annually) / $4,072.58 - 4,751.25 monthly
(48,871 – 57,015 annually) / $4,591.33 - 5,356.46 monthly
(55,096 - 64,278 annually) / $5,111.33 - 5,963.13 monthly
(61,336 - 71,558 annually)
$45.00 / $4,147.58 - 4,740.00 monthly
(49,771 - 56,880 annually) / $4,751.33 - 5,430.00 monthly
(57,016 - 65,160 annually) / $5,356.54 - 6,121.67 monthly
(64,279 - 73,460 annually) / $5,963.21 - 6,815.00 monthly
(71,559 - 81,780 annually)
Pay at 100% / $4,740.08 or more monthly
(56,881 or more annually) / $5,430.08 or more monthly
(65,161 or more annually) / $6,121.75 or more monthly
(73,461 or more annually) / $6,815.08 or more monthly
(81,781 or more annually)

If your FAMILY size is greater than ONE, please complete the following section. Use the back of next page if more space is needed.

First Name Last Name Relationship to Patient

Dependent? ¨ Yes ¨ No Monthly Income: ______

Household Member? ¨ Yes ¨ No

Date of Birth: ______SSN: ______

Gender: ¨ Male ¨ Female ¨ Transgender

First Name Last Name Relationship to Patient

Dependent? ¨ Yes ¨ No Monthly Income: ______

Household Member? ¨ Yes ¨ No

Date of Birth: ______SSN: ______

Gender: ¨ Male ¨ Female ¨ Transgender

First Name Last Name Relationship to Patient

Dependent? ¨ Yes ¨ No Monthly Income: ______

Household Member? ¨ Yes ¨ No

Date of Birth: ______SSN: ______

Gender: ¨ Male ¨ Female ¨ Transgender

Have you been to the hospital or Emergency Room in the last 12 months? Yes No

Have you seen a medical provider (Doctor, Mental Health Counselor, etc.) in the last 12 months? Yes No

If you have answered Yes to the above questions, a signed release of medical records is needed.

PAYMENT FOR SERVICES

PLEASE PROVIDE YOUR INSURANCE CARD AT THE TIME OF REGISTRATION.

INSURED?
YES
NO / Bring a copy of your insurance card to your first appointment. Your first visit will include a 15 minute intake appointment.
LEGAL NAME AND SEX / Affinity Health Center will bill the insurance company with your legal name and legal gender marker.
INSURANCE
INFORMATION / Name of Your Insurance Company: ______
Insurance Identification Number: ______
Insurance Group Number: ______
Insurance Contact Telephone Number (On Back Of Your Card): ______
In whose name is your insurance? Self Other
If other, please provide Name and Date of Birth of Guarantor: ______
-Guarantor’s SSN: ______
Is the responsible party an Affinity Health Center Patient? Yes No

DEMOGRAPHICS

Housing & Partnership Status Agricultural Status______

Married Partnered Single or Divorced

Doubling up/Friends or Family Public Housing Dependent of Migrant Not Agricultural Worker

Homeless Shelter Transitional Other ……….. Dependent of Seasonal Seasonal Worker

Not Homeless Street/Homeless Unknown Migrant Worker

Language / English Spanish Italian Japanese Chinese French German
Need translation services Sign Language Am hearing disabled and need interpreter services
Other (please specify): ______
Race / African American/Black
(including Africa and Caribbean)
Caucasian/White (including Middle Eastern)
American Indian or Alaska Native
(including all Original Peoples of the Americas) / Asian (including Indian
subcontinent and Philippines)
Native Hawaiian
Other Pacific Islander / Unreported/Refused to Report
Multiple Races
Hispanic
Other; specify:
______
Ethnicity / Non-Hispanic/ Non-Latino / Hispanic or Latino
(including Spain) / Unreported/Refused to Report
Veteran? / Yes No Unknown / If yes, are you eligible for benefits?
Yes No Unknown
Birth Sex (Please Check One) / Male Female
To be completed by patients over 16
Do you Identify as Transgender? / Yes No / Preferred pronoun: He/him She/her Other: ______
Sexual Orientation / Gay/Lesbian / Straight / Bi-sexual / Other: ______

EMERGENCY CONTACT

Please provide contact information for the person you want us to contact in the event of an emergency. We will identify ourselves as Affinity Health Center in the event of an emergency.

First Name: / Last Name: / Relationship:
Street Address: / Apt.#
City: / State: / Zip Code:
Home#: / Work#:


Register me for the Patient Portal. An email address and access to the internet are required to use the Patient Portal.
PRINT your email address below. A welcome email with instructions will be sent to this email address.


How did you hear about Affinity Health Center? ______

By signing my name below, I am acknowledging that I have completed each with correct and honest information.

(Patient or Guardian)
Signature: / Date:


Additional FAMILY members if your FAMILY size is greater than ONE (continued from previous page).

First Name Last Name Relationship to Patient

Dependent? ¨ Yes ¨ No Monthly Income: ______

Household Member? ¨ Yes ¨ No

Date of Birth: ______SSN: ______

Gender: ¨ Male ¨ Female ¨ Transgender

First Name Last Name Relationship to Patient

Dependent? ¨ Yes ¨ No Monthly Income: ______

Household Member? ¨ Yes ¨ No

Date of Birth: ______SSN: ______

Gender: ¨ Male ¨ Female ¨ Transgender

First Name Last Name Relationship to Patient

Dependent? ¨ Yes ¨ No Monthly Income: ______

Household Member? ¨ Yes ¨ No

Date of Birth: ______SSN: ______

Gender: ¨ Male ¨ Female ¨ Transgender

First Name Last Name Relationship to Patient

Dependent? ¨ Yes ¨ No Monthly Income: ______

Household Member? ¨ Yes ¨ No

Date of Birth: ______SSN: ______

Gender: ¨ Male ¨ Female ¨ Transgender

First Name Last Name Relationship to Patient

Dependent? ¨ Yes ¨ No Monthly Income: ______

Household Member? ¨ Yes ¨ No

Date of Birth: ______SSN: ______

Gender: ¨ Male ¨ Female ¨ Transgender

First Name Last Name Relationship to Patient

Dependent? ¨ Yes ¨ No Monthly Income: ______

Household Member? ¨ Yes ¨ No

Date of Birth: ______SSN: ______

Gender: ¨ Male ¨ Female ¨ Transgender

First Name Last Name Relationship to Patient

Dependent? ¨ Yes ¨ No Monthly Income: ______

Household Member? ¨ Yes ¨ No

Date of Birth: ______SSN: ______

Gender: ¨ Male ¨ Female ¨ Transgender

First Name Last Name Relationship to Patient

Dependent? ¨ Yes ¨ No Monthly Income: ______

Household Member? ¨ Yes ¨ No

Date of Birth: ______SSN: ______

Gender: ¨ Male ¨ Female ¨ Transgender

CONSENT FOR TREATMENT

In order for you to become a patient, we need your consent to provide you with care. We also need you to acknowledge that we have provided you with certain important information and documents. If you have any questions about any of this information or need help completing this form, please do not hesitate to ask a member of our staff. It is important to us that you feel comfortable with all of this information. By signing, you are indicating that you understand the information, have been given a chance to ask questions, and are giving your consent.

GENERAL CONSENT TO TREAT

I voluntarily agree to receive services from Affinity Health Center, and authorize the providers of AHC to provide such care, treatment, or services as are considered necessary and advisable for me. I understand that I should participate in the planning for my care and that I have a right to refuse interventions, treatment, care, services or medications at any time to the extent the law allows. I know that the care I will receive may include tests, injections, and other medications, etc., that are based on established medical criteria, but not free of risk. HIV Testing is included as a routine part of care unless I, the patient, elect to decline testing which should be done by notifying the medical provider. Should it be necessary, I authorize AHC staff to obtain emergency medical assistance for me from the Emergency Medical Service and/or hospital.

INTEGRATED MODEL OF CARE

AHC offers a wide variety of services for its patients. I understand that in order for me to get the best care possible, programs within AHC may share information concerning my health to ensure the quality and continuity of my care across service areas. I also understand that services are delivered by a multi-disciplinary team under the supervision of a physician. I authorize my provider to discuss with parties outside AHC information including diagnosis(es), case history, physical examinations, treatments, and hospitalizations—deemed necessary and appropriate to deliver medical care to me. I request that my protected health information be communicated with others directly involved in my care. The designated care provider listed will keep a copy of this document as a permanent part of my medical record which will be copied as required in order to allow communication of my protected health information, in accordance with HIPAA. I understand that my health care providers will use judgment in determining the minimum amount of information that must be shared to care for me.

SATELLITE SERVICES

I consent to have the Family Resource Center staff at AHC satellite sites assist in the provision of services to me including, but not limited to, interpretation, faxing records, and providing administrative support to AHC staff. All Family Resource Center staff members are business associates of Affinity Health Center and are bound by HIPAA.

PATIENT RIGHTS AND RESPONSIBILITIES

I have been given a copy of the AHC Patient Rights and Responsibilities document and understand that both the Rights and Responsibilities laid out in that document must govern my interactions at AHC. I also understand that AHC and I are responsible for adhering to the Rights and Responsibilities. I understand that I have a right to file a complaint with AHC, as described in the Patient Rights. The Patient Rights contains information about being a patient at AHC and services that AHC offers.

RELEASE OF INFORMATION FOR BILLING

I know that AHC may send parts of my personal health information to organizations that help pay for my care, such as my insurance company or an organization that grants money to AHC. I allow AHC to release the relevant parts of my record so that my care can be paid for. If I do not feel comfortable with this, then I understand that I can request a higher level of privacy protection that is afforded me under the Health Insurance Portability and Accountability Act (HIPAA).

ACKNOWLEDGEMENT OF DUTY TO REIMBURSE AHC FOR HEALTH CARE SERVICES

I understand that AHC offers a Discounted Fee Schedule to individuals who are deemed unable to pay based on their level of income. In order to be eligible for AHC’s Discounted Fee Schedule, I will need to provide AHC with documents establishing that I meet income eligibility requirements.