• Shalom Health Care Center

    PROVIDING QUALITY HEALTH CARE THAT IS PATIENT-CENTERED, AFFORDABLE, AND ACCESSIBLE FOR ALL IN OUR COMMUNITY
  • Shalom Health Care Center

    PROVIDING QUALITY HEALTH CARE THAT IS PATIENT-CENTERED, AFFORDABLE, AND ACCESSIBLE FOR ALL IN OUR COMMUNITY
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  • PATIENT INTAKE CHECKLIST
    1. I have received a copy of the notices listed below. My initials by each notice indicate that I  have received that notice and my questions have been answered. As a patient of Shalom  Health Care Center, I agree to the policies and procedures in those notices.
  • Patient/Provider Agreement
    Missed Appointment (No-Show) Policy
    Expected Payments Policy
       Patient Portal    
    Email:
    Patient Consent for Treatment and Notification of Use and Disclosure of Protected Health Information
    Notice of Privacy Practices

  • 2. I understand Shalom Health Care Center utilizes the following methods to contact me
    regarding my care and/or leave messages regarding my care via the following method(s):
  • 3. I have completed the “Patient Registration Form” and (if applicable) “Patient Consent for  Treatment of a Minor and/or Release of Information to Others” to the best of my ability and I request that information on those forms be included in my/my child’s health records.
    4. I give my consent to be examined and/or treated by Shalom Health Care Center’s health care providers. I understand and agree that any in-depth examination and/or procedure will be explained to me before I give my consent.
    5. All documents, policies, and procedures included in the Shalom Health Care Center intake  process have been explained to me, and I understand that if I have any questions, I may ask a Shalom staff member at any time.
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  • The Center receives federal funding from Department of Health and Human Services (HHS) and has Federal Public Health Service (PHS) deemed status with respect tocertain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

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