• Shalom Health Care Center

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

    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.
  • Clear
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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.

    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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