Volunteer Health Care Provider Program Eligibility Form

VOLUNTEER HEALTH CARE PROVIDER PROGRAM ELIGIBILITY FORM

CLINIC/PROGRAM/PROVIDER: GRACE MEDICAL HOME
Section 1
Does the client/patient have insurance that covers the health or dental condition?*

YESNO
Does anyone in the client/patient’s family have an active FL Medicaid card?*

YESNO
Name of the Card Holder*

First NameLast Name
Medicaid Card Number*
Client/Patient/Head of Household's Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number*

Area CodePhone Number
Section 2
For the grid below, please only include any dependents in the household under the age of 21. Other independent adults living in the household must apply separately.

Family Size*

	Adults	Under 18	18-21 Student	Unborn
How many in your household?

Family Members*

	Name	D.O.B.	Employer	Gross Earned Income Last 4 Weeks	Gross Unearned Income Last 4 Weeks (Do not include TCA or SSI)
Self
Spouse/Partner
Child
Child
Child
Child
Child
Child

TOTAL Gross Earned Income Last 4 Weeks*
TOTAL Gross Unearned Income Last 4 Weeks (Do not include TCA or SSI)*
TOTAL Income*
Today's Date

MonthDayYear
Date
Grace Medical Home is offering a new text, email, and automated voice message program to patients (CareMessage). Examples of these messages are reminders and information about health education programs. This is a consent form. Signing this form is voluntary. Whether or not you sign, the treatment you receive from us will be the same.

Cost: There is no fee to be part of this Program. Standard text message and minute usage rates from your mobile or Internet service provider may apply.

Risks: Sending and receiving text, email and voice messages from us may impact the privacy and security of your Personal Health Information (“PHI”). Examples of PHI are: name, medical condition or insurance coverage.
- Text, email and voice messages are not encrypted. Encryption makes sure your information stays safe. Information in text, email and voice messages may not be secure.
- If you share your phone or email, or your mobile phone is lost or stolen, someone other than us may be able to access your PHI. Messages can be read, used or shared by people other than us.
I, the Patient, understand and accept each of the following:
- I authorize Grace Medical Home to send me text, email and voice messages. This includes (but is not limited to) treatment- or care-related reminders and health education information.
- Text, email, and voice messages from Grace Medical Home may contain PHI. I will be responsible for information I share with Grace Medical Home.
- This consent will be in effect as long as I receive treatment from Grace Medical Home. I can ask Grace Medical Home for a more secure form of communication, such as telephone or fax.
- I will let Grace Medical Home know if my mobile phone number changes or if I no longer want to be part of this Program, by mail, email or phone call.
- This consent is good for five (5) years. I can cancel by signing a cancellation form.
- I have a right to receive a copy of this consent form for my records.
I have read the above information and, by signing below, I confirm:*

Yes! I want to participate in this Program.No. I do not want to participate in this program.
Mobile Phone Number*

Area CodePhone Number
Landline Phone Number*

Area CodePhone Number
Email*
example@example.com
Signature of Patient or Patient's Representative*

Clear
Date

MonthDayYear
Date
Name of Patient or Patient's Representative*
Representative's Relationship to Patient
Should be Empty:

VOLUNTEER HEALTH CARE PROVIDER PROGRAM ELIGIBILITY FORM

Section 1

Section 2