• PATIENT ANNUAL REGISTRATION

    This application expires twelve (12) months from the date signed and must be resubmitted annually.

  • Patient Name:    
    Date of Birth: Pick a Date  
    Address:    
    Preferred Phone:    Alternate Phone:    
    If patient is a minor who is the legal guardian for child?    
    Relationship:
    Emergency Contact Name:    Relationship:
    Phone:     Email:

  • Patient Name:    
    Date of Birth: Pick a Date  
    Address:    
    Preferred Phone:    
    Alternate Phone:    
    If patient is a minor who is the legal guardian for child?    
    Relationship:
    Emergency Contact Name:    
    Relationship:
    Phone:    
    Email:

  • My initials by each notice indicate that I have received that notice and my questions have been answered. Copies of Notice of Privacy Practices and Patient Consent for Treatment and Notification of Use and Disclosure of Protected Health Information are available upon request

  • 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.
    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.

  • Clear
  •  -  -
    Pick a Date

  • Would you like to apply for Sliding Fee Scale?         

  • Signature: *   

  • Do you have private health insurance?         
    Are you part of a state or federally funded Program?          

  •          

  • If you want to apply for Sliding Fee Scale, list all family members currently living in household, including Patient.

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  • AUTHORIZATION: I hereby authorize any bank or financial institution, government agency or department, hospital, physician, corporation or individual to furnish any information concerning this application to any authorized agent of Shalom Health Care Center, Inc. Under penalty of perjury, I affirm the above information is true and correct to the best of my knowledge. I further authorize the Shalom Health Care Center to release any information regarding services rendered by any provider to my health insurance company and, in case of Medicare, to the Centers of Medicare and Medicaid Services and its agents; and allow a photocopy of my signature to be used to file insurance, including Medicare, when applicable. I request that payment, including Medicare authorized  benefits, be made on my behalf to Shalom Health Care Center. Regardless of my health insurance benefits, if any, I understand I am financially responsible for the fees for covered services and any costs incurred. I further understand  that if my account is turned over to a collection agency, I will be responsible for any interest charges allowed at the current legal rate, collection fees, reasonable attorney fees and court cost.

  • Signature   *   Date   Pick a Date*   

  • Signature   *   

    Date   Pick a Date*   

  • THANK YOU FOR CHOOSING SHALOM HEALTH CARE CENTER, INC.

  • The Center receives federal funding from Department of Health and Human Services (HHS) and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

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