Clinic (E) New Patient Registration 09.2020

PAYMENT FOR SERVICES AT AN OUTSIDE HEALTHCARE FACILITY

In the event that you seek services at an alternative healthcare facility or receive a referral from a healthcare provider at Texas Native Health to avail services elsewhere, it is imperative to acknowledge that you bear the responsibility for covering the associated costs. Should you possess alternative resources such as private insurance, Medicare, or Medicaid, it will be your responsibility to furnish this pertinent information to the alternate establishment.

CONSENT TO TREAT

The undersigned hereby gives consent to the staff of Texas Native Health Clinic for medical examination, treatment, laboratory services, and professional services, including but not limited to: Behavioral health and Dental to the undersigned and/or minor child listed below.

MAINTAINING "CURRENT MEDICAL PATIENT" STATUS

A "Current Medical Patient" is defined as an individual who has received medical attention from a healthcare provider within the preceding three years. In accordance with legal regulations, prescriptions accompanied by refills have a validity period of one year. To sustain access to prescribed medications, it is imperative to adhere to the practitioner's treatment plan and ensure attendance at scheduled appointments. Failure to have been seen by a healthcare provider within a span of one year will render individuals ineligible to receive prescription renewals.

PATIENT INFORMATION BROCHURE

I hereby acknowledge receipt of the Texas Native Health Patient Information Brochure the outlines Patient Rights and Responsibilities.
NOTICE OF PRIVACY PRACTICES*

I acknowledge and request a copy of Texas Native Health's Notice of Privacy PracticesI acknowledge and decline a copy of Texas Native Health's Notice of Privacy Practices.
HIPAA PRIVACY ACT / RESPONSIBLE PARTY ACKNOWLEDGEMENT

I hereby acknowledge that I have thoroughly reviewed the HIPAA Privacy Act Notice. I am cognizant that my medical records are currently maintained or will be archived within the Health and Medical Records System located at 1283 Record Crossing Rd., Dallas, Texas 75235.

Having solicited medical care services from Texas Native Health for myself and/or my family, I authorize the assignment of benefits for all rendered services to be remitted to Texas Native Health.

I comprehend that the information furnished by me and/or gathered and preserved in my health record is indispensable for the provision of services to promote my health and well-being by the staff of Texas Native Health or its contracted service providers. Moreover, I have been duly apprised that my health record, or any segment thereof, shall not be disclosed to any external agency or individual, unless categorized as routine use, without my explicit consent.
Patient's Name
Signature of Patient (or Parent/Legal Guardian for Minor)

Clear
Date

MonthDayYear

	Yes	No
Are you a migrant worker?
Are you currently homeless?

	Full Name	Phone Number	Relationship	Address
Emergency Contact
Next of Kin

	Full Name	Address	Phone Number	Email
Mother
Father

	Yes	No
Do you have Medicare?
Do you have Medicaid/CHIP?
Do you have dental insurance?
Do you have private or group insurance?

	Diagnosed	Year
AIDS/HIV
Allergies
Arthritis
High Blood Pressure
Breast Cancer
Colon Cancer
Cervical Cancer
Ovarian Cancer
Other Cancer
Blood Transfusion
Liver Disease
Diabetes
Glaucoma
Heart Disease
Hemophilia
Hepatitis B
Hepatitis C
Asthma
Kidney Trouble
Emphysema
Epilepsy
Psychiatric Problems
Rheumatic Fever
Rheumatism
Stroke
Syphilis
Tuberculosis (TB)
Thyroid Disease

	Medication Name	Dosage	Frequency	Reason for Taking
1
2
3
4
5
6
7
8

	Living	Deceased	Cause of Death
Mother
Father
Sibling(s)

	Received	Year	Normal	Abnormal
Colonoscopy
Mammogram
Pap Smear

	Hospital	Reason for Admission/Surgery	Year
1
2
3

Initial Medical History Questionnaire