Schedule an Appointment

Welcome to People's Center!

(If this is an emergency please dial 911) This form should only take 10 minutes, and even less if you're already one of our patients! You'll receive a confirmation call soon after you submit your form, or the next work day morning for after hours submissions. See you soon!
Are you a current People's Center patient? (behavioral, medical, or dental patient)*

YesNo
Please Note!

New patients are admitted based on our capacity. If you haven't received care from us before, you may fill out the form below
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Select your preferred appointment dates and times (up to three)
What kind of visit is this?*

MedicalDentalBehavioral
What brings you in to People's Center?*
Patient Registration

If you aren't a current People's Center patient, make sure to fill out the information below! All information is safe on our HIPPA secure servers.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*
City*
State*
Zip Code*
Phone*
Cell/Alternative Phone
Social Security No.
Driver's License No
State
Marital Status*

SingleMarriedWidowedDivorced
Gender*

MaleFemaleTransgender Female / Male-FemaleTransgender Male / Female-MaleChoose not to discloseNon-binary / Gender QueerQuestioningOther
Employer.
Work Phone#
Employer's Address
School Name, if student
Interpreter Name, if applicable
Interpreter Phone Number
Preferred Language*

EnglishSomaliOromoAmharicArabicSpanishOther
Please select your answers below and check your Race and Ethnicity (for funding reports only; no names are disclosed)*

African BornAfrican AmericanAsian / Pacific IslanderHispanicNative AmericanCaucasianOther
Country of Origin*
Tobacco Use

DailyOccasionalEnvironmental ExposureQuit UseNever Smoked
Family Size (Includes all family members within the household)
Income

$0 - $25,000$75,100 - $100,000$25,100 - $50,000Over $100,000$50,100 - $75,000
EMERGENCY CONTACT
Name
Phone
Relationship to patient
INSURANCE INFORMATION
Do you have insurance?*

YesNo
Insurance Company Name
Insurance Company Address
Group Number from card
Insured ID#
RESPONSIBLE PARTY (PERSON RESPONSIBLE FOR PAYING THE BILL IF NOT PATIENT)
Name*
Date of Birth*

MonthDayYear
Date
Address
City
State
Zip Code
Relationship
DO YOU HAVE A LIVING WILL OR ADVANCE DIRECTIVE?
Yes
No
If Yes, date filed

MonthDayYear
Date
I HEREBY AUTHORIZE SERVICES RENDERED TO ME BY PEOPLE’S CENTER AND AGREE TO PAY FOR SUCH SERVICES INCLUDING . THOSE SERVICES CONSIDERED NON-COVERED OR DENIED BY MY INSURANCE COMPANY*

ASSIGNMENT OF BENEFITS -- I hereby authorize payment of the amount due to me in my pending insurance claim be made directly to People's Center Clinics & Services. Payment is authorized upon your receipt of an itemized statement of services.PRESCRIPTION HISTORY RELEASE -- I hereby authorize People's Center Clinics & Services to view my prescription history when providing evaluation or treatment services to me.RECORDS RELEASE -- I hereby authorize the exchange / release of any information, via paper or electronic review by People's Center Clinics & Services with any providers, hospitals and / or specialist(s) to whom I may receive care from, be referred for care, or to my insurance company to determine benefits and secure payment for services provided.
HEALTH DATA EXCHANGE*

Yes, I authorize my insurer, health plan, or claims administrator and provider to share with each other my health information for care coordination and quality improvement purposes. This includes sharing my health information from treatment I have received at health care providers not related to People's Center Clinics & Services. My insurer, health plan or claims administrator may also share the above information with a care system or accountable care organization in which People's Center participates. If I do not want my health information shared for these purposes, I may opt out by initialing the statement belowNo, I do not authorize my insurer, health plan, or claims administrator and provider to share my health information as described above.
NOTICE OF PRIVACY PRACTICE

People's Center Clinics & Services is part of an organized health care arrangement including participants in OCHIN. A current list of OCHIN participants is available at www.ochin.org as a business associate of People's Center OCHIN supplies information technology and related services People's Center and other OCHIN participants. OCHIN also engages in quality assessment and improvement activities on behalf of its participants. For example, OCHIN coordinates clinical review activities on behalf of participating organizations to establish best practice standards and assess clinical benefits that may be derived from the use of electronic health record systems. OCHIN also helps participants work collaboratively to improve the management of internal and external patient referrals. Your health information may be shared by People's Center with other OCHIN participants or a health information exchange only when necessary for medical treatment or for the health care
operations purposes of the organized health care arrangement. Health care operation can include, among other things, geocoding your residence location to improve the clinical benefits you receive.

The personal health information may include past, present and future medical information as well as information outlined in the Privacy Rules. The information, to the extent disclosed, will be disclosed consistent with the Privacy Rules or any other applicable law as amended from time to time. You have the right to change your mind and withdraw this consent, however, the information may have already been provided as allowed by you. This consent will remain in effect until revoked by you in writing. If requested, you will be provided a list of entities to which your information has been disclosed.
CONSENT TO PRIVACY PRACTICES*

I acknowledge that I was given/offered the Notice of Privacy Practices today, OR at a previous visit.
INFORMED CONSENT FOR TELEHEALTH CONSULTATIONS

Because telehealth services are a different type of consultation and patients need to be informed, the patients need to understand and consent to the consultation terms. The following consent should be signed by your patient and incorporated into your Notice of Patient Privacy.

All patients receiving Telehealth Consultations will need to review and consent to the following consultation terms:

1. The consulting health care provider or specialist will be at a different location from me. I will connect to the virtual visit from home.

2. I will be informed if any additional personnel are to be present other than myself, individuals accompanying me, and the clinician or specialist. I will give my verbal permission prior to the entry of the additional personnel.

3. The provider will keep a record of the consultation in my medical record.

4. RELEASE OF INFORMATION: (People's Center Clinics & Services) and/or providers who provide professional services to the patient are authorized to furnish medical information from my medical record to the referring physician, if any, and to any insurance company or third party payer for the purpose of obtaining payment of the account. (People's Center) is authorized to release information from my medical record to any other health care facility or provider to which my care may be transferred.

5. I voluntarily consent to health care services provided by my doctor(s) or a designee, which may include diagnostic tests, drugs, and examinations.

6. I understand that I have the option to refuse telehealth service at any time without affecting the right to future care or treatment and without risk losing benefits. I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons.

7. I understand that if I do not choose to participate in a telemedicine session, no action will be taken against me that will cause a delay in my care and that I may still pursue face-to-face consultation.

8. I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see a specialist in person.
TELEHEALTH CONSENT*

I acknowledge that I was given/offered the Informed Consent for Telehealth Services today, OR at a previous visit.
Patient/Guardian Signature.*

Clear
Date*

MonthDayYear
Date
How Did You Hear About People's Center Health Services

Family Members and FriendsThe Current / MPRReferral from other organizationInternet SearchAdvertisementSocial MediaOutreach / Community EventOther
FOR OFFICE USE ONLY:
Chart/MRN#
Primary Care Provider
Should be Empty:

Welcome to People's Center!

Please Note!

Patient Registration