Patient Name

{name}

It is a grant requirement that we collect this information for all patients, so please give us at least an estimate of what you receive weekly, monthly or annually. To apply for discounted fees, please attach copies of last year’s income tax return; paycheck stubs from last two pay periods; last month’s unemployment checks; proof of other household income (social security, SSI, child support. alimony, pension, veterans’ benefits, workers’ compensation, public assistance and/or unemployment benefits for all household members). 

You have 30 days from date of service to provide this information.  If you are self-employed, please submit your most recent year’s tax return. 

Please note failure to provide complete documentation will result in sliding fee not being applied and patient will be responsible for all charges.

If yes, please specify type of business and gross income AND attach a copy of last year's 1040 Tax Return:

I AGREE THAT THE ABOVE INFORMATION IS CORRECT AND ALL SOURCES OF INCOME HAVE BEEN REPORTED. I WILL REPORT ANY INCOME CHANGES AND WILL RE-APPLY EVERY SIX MONTHS EVEN IF NO CHANGES OCCUR. FAILURE TO MEET THESE CONDITIONS MAY DISQUALIFY ME FROM FUTURE KCHC FEE DISCOUNTS

Patient Name

{name}

Date of Birth

{dateOf}

I give consent and authorize health care services involving evaluation, counseling and recommended treatment by the providers at Kenosha Community Health Center, Inc. I understand that these procedures may include routine diagnostic (testing), radiology (X-rays), laboratory procedures, medication administration, and anesthetic administration.

I have read the consent form, or it has been read to me, and I understand its contents. My questions have been answered to my satisfaction.

This section is to be completed for children under the age of 18 by only a parent or legal guardian.

I affirm that I am the parent or legal guardian for the above-named minor child. If I am unable to accompany my child, I give permission for the individual(s) named below to accompany my child to his/her treatment appointment(s): For Patients over 18: I give the individual(s) named below permission to call KCHC  regarding scheduling & financial aspects.

This consent shall be considered in effect until rescinded or revoked.

Telehealth is the delivery of health care services (medical, behavioral health, dental) using interactive audio and visual electronic systems between a provider and a patient that are not in the same physical location. These services may also include electronic prescribing, appointment scheduling, communication via email or electronic chat, electronic scheduling, and distribution of patient education materials.

I consent for {name}, Date of Birth {date11} to engage in telehealth services with Kenosha Community Health Center. I understand and agree to the following for the duration of telehealth services with Kenosha Community Health Center:

1.    I have the right to withhold or remove consent for telehealth services at any time without affecting my right to future care or treatment, nor endangering the loss or withdrawal of any program benefits to which I would otherwise be eligible.

2.    The laws that protect the confidentiality of my personal information also apply to telehealth.  As such, I understand that the information released by me during the course of my sessions is confidential, just as it would be if I were in the clinic.  I understand that mandated reporting laws will be followed by my provider during telehealth visits.

3.    I understand that telehealth visits are transmitted via HIPAA approved platforms and that providers will take all reasonable measures to ensure that privacy is maintained during telehealth appointments. It is my responsibility to ensure that I access the internet through secure means and that I am in a private location to conduct my session to maintain privacy.

4.    I understand that certain situations including emergencies and crises are inappropriate for telehealth services.  If I am in crisis or in an emergency, I should immediately call 911 or go to the nearest hospital or crisis facility. The provider may not be able to provide medical treatment using interactive electronic equipment nor provide for or arrange for emergency care that you may require.

5.    I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of my provider, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

6.    I understand that telehealth based services and care may not be as complete as face-to- face services and that not all therapeutic interventions, services or patients are appropriate for telehealth services. I also understand that if my provider believes I would be better served by another form of services (e.g. face-to- face services) I will be referred to a provider who can provide such services in my area.

7.    I understand that a lack of access to all the information that might be available in a face to face visit, but not in a telehealth session, may result in errors in judgment. Delays in medical evaluation and treatment may occur due to deficiencies or failures of the equipment.

8.    I understand that a limited examination may take place during the videoconference and that lab and other tests are not available via telehealth.

9.    I have the right to ask my healthcare provider to discontinue the conference at any time.

10.  I understand that no part of the telehealth visit will be recorded by my provider and agree not to record any part of the visit myself.

11.  I understand that my provider will document in my medical chart as if the visit were conducted in person with only the additional information required for telehealth billing.

12.  I understand that I, or my insurance, will be billed as authorized by my insurance and/or sliding fee plan. I have had my questions regarding billing answered to my satisfaction by the billing department.

I hereby consent to engaging in telehealth with Kenosha Community Health Center as part of my healthcare evaluation and treatment. I understand that "telehealth" includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I have read this document and understand the risk and benefits of the telehealth services and have had my questions regarding the services answered to my satisfaction.

Patient Name

{name}

Date of Birth

{dateOf}

I hereby authorize and direct my insurance carrier(s), including Medicare, Medicaid, private insurance and any other health/medical/dental, to issue payment check(s) directly to Kenosha Community Health Center, Inc. for services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

Patient Name

{name}

Date of Birth

{dateOf}

I hereby acknowledge that a copy is available to me of the Kenosha Community Health Center, Inc. “KCHC” Notice of Privacy Practices with information about how KCHC may use and disclose my protected health information PHI and about my rights and KCHC’s duties under the Health Information Portability and Accountability Act “HIPAA” I understand that I may also request additional copies of KCHC’s Notice of Privacy Practices if I so desire.

By signing this document, I agree that I have received the following documents:

1. Patient Welcome Letter

2. No Show Policy

3. Double Booking Appointment

4. Nondiscrimination Statement

5. After Hours Access

6. Reason for Patient Dismissal