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:

  • A photo ID
  • Your most recent IRS tax form
  • 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

Please List All People Living in Your Household (not yourself)

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.

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.

CCVIM PATIENT SERVICE AGREEMENT

(Please read and check each box to agree to our policies)

PATIENT SOCIAL HISTORY

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.

PATIENT PAST MEDICAL HISTORY

Please check boxes by any conditions that you have:

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:

PATIENT INTAKE