NEW PATIENT PAPERWORK PATIENT ELIGIBILITY CHECKLIST Are you a person who has no insurance? Are you between 18 and 65 years of age? Is your income at 300% of Federal Poverty Level? Eligibility Are you from Columbia or lower Luzerne Counties? Do you need care that would be given at a doctor’s office, and not in an emergency room? If you can answer yes to all of the checklist questions, please call for an appointment at the clinic. Remember there are no walk-ins available, and that we do not prescribe any narcotics. FOR YOUR FIRST APPOINTMENT, PLEASE BRING OR SEND: A photo ID Your most recent IRS tax form OR two recent pay stubs A complete list of your medications Copies of your paperwork, if you have been to the Emergency Room or Careworks recently Before your first appointment, fill out our new patient paperwork below, and hit SEND. CCVIM REGISTRATION AND CONSENT Last Name, First Name, Middle Name(required) Sex(required) Transgender? Yes (I need a more detailed form) No Date of Birth(required) Social Security Number Street Address(required) City(required) State(required) Zip Code(required) Township or Borough(required) County(required) Home Phone Number(required) Mobile Phone Number(required) May Clinic Text You? Yes No Email May Clinic E-mail You? Yes No Language Race (check all that apply) American Indian Asian Asian Indian Black European Filipino Hawaiian/Pacific Islander Japanese Korean White Other Ethnicity Hispanic/Latino Non-Hispanic Marital Status Single Partnered Married Separated Divorced Widowed Sexual Orientation Asexual Heterosexual Bisexual Homosexual Other- please describe: Total Number of People in Household Including Yourself(required) Total Yearly Household Income (approximate)(Proof of Income Required Yearly)(required) Please List All People Living in Your Household (not yourself) Name – Relationship – Age – Employer Name – Relationship – Age – Employer Name – Relationship – Age – Employer Name – Relationship – Age – Employer Name – Relationship – Age – Employer How Did You Hear About CCVIM?(required) Advertising- Billboard, poster, flyer, or banner Word of Mouth A CCVIM Patient Doctor Hospital Agency Church Website/online If you have a card from our Referral Rewards Program, Enter Rewards # here: Emergency Contact(required) Relationship(required) Their Phone Number(required) Your Preferred Pharmacy Name and City(required) Preferred Geisinger Lab Location(required) All information gathered by CCVIM is for statistical purposes to seek funding. We don’t discriminate on ANY basis. Authorization to Treat:By putting my name in the box below, I authorize Columbia County Volunteers in Medicine volunteer professionals and staff to treat me. Patient name(required) Today's Date(required) FEDERAL TORT CLAIM ACT (FTCA) NOTIFICATION: 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 health care practitioners who have provided a required or authorized service under Title XIX of the Social Security Act (i.e. Medicaid Program) at a free clinic site, or through offsite programs or events carried out by the free clinic. {See 42 U.S.C. 233(a), (o)} The above Federal law and other State and Federal laws, including the Federal Volunteer Protection Act of 1997, may cover certain health clinic professionals providing health care services to patients at Columbia County Volunteers in Medicine Clinic, Inc. By putting my name in the box below, I acknowledge that I have read and understand the above statement. Patient name:(required) Today's Date(required) Do you have any type of health insurance?(required) Yes No If yes, what kind of insurance? Have you applied for Medical Assistance?All patients must apply at http://www.compass.state.pa.us and if refused MA this past year, provide Letter of Denial (required) Yes No If you have ever served in the Army, Navy, Air Force, Marines, Coast Guard, or National Guard, have you applied for Veteran's Benefits?(required) Yes No Did you file Federal Income tax?CCVIM must have a copy on file each year. You can request a copy from IRS at 1-800-829-1040.If you did not file Income Tax because you had no income, or you were paid cash, please fill out CCVIM Zero Income Statement(required) Yes No CCVIM PATIENT SERVICE AGREEMENT (Please read and check each box to agree to our policies) I understand that Columbia County Volunteers in Medicine Clinic serves patients who have no insurance and fall within 300% of the Federal Poverty Guidelines. If I have insurance or my income changes, I agree to notify CCVIM. To continue using CCVIM services keeps other members of our community who need help from getting it, and could even cause the Clinic to close. I understand that CCVIM is not an Emergency Room, nor is it a walk-in clinic, and I must be responsible for my own safety and health by seeking out, and paying for, my own care in an urgent health crisis. I will treat the CCVIM clinic with the same respect as any other Primary Care Provider, by making, keeping, and cancelling appointments. I will inform CCVIM after any hospitalizations. I agree to follow the recommendations of the volunteer medical providers to the best of my abilities on medications, lab tests, referrals, and specialists for my condition. I understand that CCVIM will not be able to pay for these, and I will tell staff if I cannot afford them so CCVIM can look for ways I can get help. I agree to apply for any health insurance that I qualify for and to keep CCVIM informed of the progress. I understand that CCVIM does not have any narcotic medications ("pain killers") at the clinic, nor does the clinic prescribe narcotics to our patients. I agree to take all medications as directed, keep in contact with CCVIM staff about medication changes, including if I stop taking it, or if I notice any side effects. I agree to try to contact CCVIM about refills before I run out. I understand that there may be times that CCVIM must cancel or reschedule my appointment due to circumstances beyond the clinic's control such as weather, or volunteer staffing changes, and that the clinic will notify me of those changes as soon as they know. I understand that the majority of staff at CCVIM are volunteers who treat all patients with dignity and respect in a professional atmosphere. If I am in any way unsatisfied with my interactions with staff or treatment at the clinic, I agree to ask to speak to a person in authority, or to call the clinic at 570-752-1780. Out of respect for the care provided to me, I agree to treat all staff with equal dignity and respect. I understand that if I am abusive towards CCVIM staff or property, with profanity, language, threats, actions, or violence of any kind, the clinic has the right to dismiss me from the clinic's services,and may call the police and press charges, if needed. For the safety of everyone, weapons of any kindwill not be tolerated at the clinic. I understand that CCVIM will use the same confidentiality practices as any other medical provider. Any information related to my care will not be shared with my family, friends, community members, employers, or outside agencies, except as authorized in writing by me. PATIENT SOCIAL HISTORY Education?(required) Less than 8th grade 8th grade 9th 10th 11th 12th grade graduate or GED 2 year college 4 year college Post graduate Occupation?(required) Number of children? Exercise level?(required) None Occasional Moderate Heavy General stress level?(required) Low Medium High Diet?(required) Regular Vegetarian Vegan Gluten free Low Carbohydrate Cardiac Diabetic Caffeine intake? (400mg per day = 2 energy drinks, 3 coffees, 7 sodas, or 9 teas)(required) None Under 400 mg daily (Occasional) Around 400 mg daily (Moderate) Over 400 mg daily (Heavy) Smoking status?(required) Never Former Current daily Current occasional I would like help quitting Smoking- how much? None One pack per week Two packs per week 1/4 pack per day 1/2 pack per day One pack per day 1 and 1/2 packs per day Two packs per day 3 or more packs per day Smoked since age? Smokeless tobacco status?(required) Never used Former user Current snuff user Current chewing tobacco user Current moist powdered tobacco user E-cigarette/vape status?(required) Never used Former user Current user Passive smoke exposure?(required) Yes No Alcohol use?(required) None Occasional (one drink per day or less) Moderate (two drinks per day) Heavy (3 to 5 drinks per day) If you think your alcohol use is becoming a problem that is difficult to control, or if you experience withdrawal symptoms, please describe: Besides alcohol, some people use substances that are not prescribed for them. In order to safely treat you, our doctors need to know what you might be using. Please include: Cannabinoids like marijuana, Opioids like heroin, fentanyl, or oxycodone, Stimulants like cocaine, Adderall, amphetamines, or meth, Sedatives like barbiturates, Valium, Xanax, benzos, and Z-drugs like Ambien or Lunesta, Club drugs like ecstasy or GHB, Dissociatives like Ketamine, PCP, Salvia, or DXM, Hallucinogens like LSD, acid, mescaline, mushrooms, or DMT, Inhalants like gasoline, canned gases, nitrous oxide, or poppers, Synthetics like K2 or Spice, or Steroids. Substance use?(required) Never Former user (but not currently) Only tried once or twice Occasionally (monthly or so) Weekly Daily I think my substance use is becoming difficult to control Please describe your substance use, including details such as type and how often: Are you sexually active?(required) Yes No Sexual partners?(required) None Men Women Both Have there been any recent changes to your family or social situation?(required) Yes No Please describe: PATIENT PAST MEDICAL HISTORY Please check boxes by any conditions that you have: Eyes Vision/Eye Problems Ears, Nose, Throat Allergies/Hayfever Chronic Ear Infections Difficulty Swallowing Ear/Hearing Problems Meniere's Disease Cardiovascular Congestive Heart Failure Coronary Artery Disease Heart Disease Heart Problems High Cholesterol Hypertension (High Blood Pressure) Varicosities Respiratory COPD Asthma Lung Disease Pulmonary Embolism Tuberculosis GastroIntestinal Constipation Diverticulitis GI Problems Polyps Reflux/GERD Endocrine Diabetes Gout Hyperthyroidism (overactive) Hypothyroidism (underactive) Obesity Thyroid Problem MusculoSkeletal Athritis Fibromyalgia Muscle/Joint/Bone Problems Osteoporosis Neurological ADD/ADHD Autism Spectrum Disorder Headaches Seizures/Epilepsy Stroke Skin Eczema Skin Problems Blood Anemia Blood Diseases Blood Transfusion Hepatiis Liver Disease Thrombophilias GenitoUrinary Bedwetting Bladder/Kidney Problems Kidney Disease Kidney Stones Mental Health Anxiety Disorder Depression Developmental/Behavioral Disorder Eating Disoder Mental Disease Mental Disorder Women Breast Cancer Breast Problem Endometriiosis Infertility Ovarian Cancer Pre-Eclampsia Other Abuse/Domestic Violence AIDS/HIV Anesthesia Complications Birth Defects/Inherited Disease Cancer Chicken Pox Hospitalizations MRSA Exposure Other Other Other PATIENT’S FAMILY MEDICAL HISTORY For each of your family members, please note any MEDICAL CONDITIONS that you know they have, or that they had: Your Mother: Your Father: Your Sister(s): Your Brother(s): Your Daughter(s): Your Son(s): Your Maternal Grandmother (mother's mother): Your Maternal Grandfather (mother's father): Your Paternal Grandmother (father's mother): Your Paternal Grandfather (father's father): PATIENT INTAKE I would PREFER an appointment: on Telehealth videochat on Monday mornings on Wednesday mornings on Thursday evenings as soon as possible Please briefly describe the current problem that you would like to be seen for:(required) Please briefly describe your chronic conditions: Please list all hospitalizations/surgery and approximate date (year): Tetanus vaccine- approximate date (year): Flu vaccine- approximate date (year): Female Pap Smear- approximate date (year): Female Mammogram- approximate date (year): I HAVE ALLERGIES TO MEDICATION, FOOD, OR ENVIRONMENT:(required) No Yes If yes, please list each MEDICATION you are ALLERGIC to, and describe the reaction: If yes, please list each FOOD you are ALLERGIC to, and describe the reaction: If yes, please list each ENVIRONMENTAL CONDITION (like pollen, animals, etc.) you are ALLERGIC to, and describe the reaction: PRESCRIPTION MEDICATIONS: please list ALL prescription medications that you take and the dose for each. Please copy the information directly from your bottle.(example: Amlodipine 5mg- One tablet daily)Please note the details here also, if you are prescribed medications that you are not taking, or if you are taking medications prescribed for someone else. NON-PRESCRIPTION MEDICATIONS, VITAMINS, HERBAL SUPPLEMENTS: please list over-the-counter medications or supplements that you take on a regular basis and the dose for each. Do you feel anxious often? Yes No Do you feel depressed often? Yes No Do you think of harming yourself? Yes No Do you feel unsafe in any of your relationships? Yes No Do you have problems from alcohol use? Yes No Send Δ Share this:TwitterFacebookLike this:Like Loading...
Columbia County Volunteers in Medicine, Inc. 