New Patient Intake forms

Thank you for your interest in becoming a patient at Volunteers in Medicine (VIM). To qualify, you must live in Comal County/New Braunfels, and fall below our income guidelines.

Once you complete the application below, please bring in proof of residency (driver's license or lease agreement in your name) and household income (last 4 paycheck stubs, last year's tax return, food stamp award letter, disability, child support...)

Please call the office if you have any questions.
Do you live in Comal County or have a New Braunfels address? *

Yes No
Health Insurance- please check if applicable

I have health insurance I have Medicare I have Medicaid I have VA
Thank you for applying. At this time you do not qualify to be a patient. Please call the office at 830-632-5131 if you wish to discuss further.
Date *

Month Day Year
Date
Name *

First Name Last Name
Email
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Date of Birth *

Month Day Year
Date
Social Security
Gender *
Marital Status *
How do you identify yourself:

Asian Caucasian Black Hispanic N/A Other
Church Affiliation (optional)
Occupation/Job Title
Total number in household *

Household Income per Month

	Job #1	Job #2	Child Support	Food Stamps	Unemployment	Disability	Housing Benefits	Other Income
Patient
Other Household Member
Other Household Member
Other Household Member
Other Household Member

Emergency Contact Name and Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Preferred Pharmacy *
I certify that the information I have given is up-to-date and correct. I understand that any falsification, misrepresentation, or withholding of information will result in the loss of eligibility to receive clinic services.
Signature

Clear
Date

Month Day Year
Date
Patient Responsibilities at Volunteers in Medicine *

I understand that the medical care at VIM is provided by volunteer doctors, nurses, and other caregivers, with a minimum of paid staff. There may be limits on availability, delays, or rescheduling. I will treat the volunteers, doctors, nurses and other medical providers with dignity and respect. If I am discourteous to staff or volunteers, I will be discharged from VIM. I understand that VIM provides basic health care and may not be able to help with all of my medical problems or provide any of the medications I need. I understand that if I have 3 no-shows in 12 months I will be discharged from VIM. All cancellations must be 24 hours before my appointment to avoid being a no-show. I will be at the clinic 15 minutes before my scheduled appointment. If I am late, I will be counted as a no-show and will have to reschedule. I agree to follow the treatment my provider advises, or I may not be able to be seen at VIM again. I understand that some lab tests and outside procedures are not free. The clinic only pays for basic laboratory services. It is my responsibility to inquire ahead of time about fees and sometimes pay for certain tests. If I am referred to an outside specialist, it is my responsibility to get directions and arrange for transportation. If necessary, it is my responsibility to arrange for payments. These tests and procedures can be very expensive, so if I miss the appointment, (and do not call both VIM and the Specialists’ office), I will be discharged from VIM. I will bring ALL medications with you for your visit, and if you are a diabetic, bring blood sugar meter and diabetic journal with you to every appointment.
Signature for Agreement for Patient Responsibilities *

Clear
Date

Month Day Year
Date

Consent to Treatment by Volunteers in Medicine Staff and Volunteer Medical Professionals

I understand that services I receive from Volunteers in Medicine may be provided by a employee and/or volunteer medical and/or dental professional that is providing care free of charge.

I further understand that state and federal law imposes a limitation on the recovery of damages from such a volunteer clinic in exchange for receiving health care services. Those limitations include immunity from civil liability for any act or omission resulting in death or injury to a patient if:

1.   The employee and/or volunteer was acting in good faith and in the course and scope of the provider's duties or functions within the organization;

2.   The employee and/or volunteer commits the act or omission in the course of providing health care services to the patient;

3.   The services provided are within the scope of the license of the employee and/or volunteer; and before the employee and/or volunteer provides health care services, the patient (or if the patient is a minor or is otherwise legally incompetent, the patient’s parent, legal guardian, or other person with legal responsibility for the care of the patient) signs a written statement that acknowledges;

a.   That the employee and/or volunteer is providing care that is not being compensated by the patient;

I HAVE READ AND UNDERSTAND THE ABOVE AND ACKOWLEDGE THAT I WILL BE TREATED BY AN EMPLOYEE AND/OR VOLUNTEER MEDICAL AND/OR DENTAL PROFESSIONAL, UNDERSTANDING THE LIMITATIONS ON THE RECOVERY OF DAMAGES DESCRIBED ABOVE FOR PATIENT.

AUTHORIZATION FOR TREATMENT

I HEREBY AUTHORIZE VOLUNTEERS IN MEDICINE STAFF AND VOLUNTEER PROFESSIONAL TO TREAT ME (IF PATIENT IS UNDER 18 YEARS OF AGE, PARENT MUST SIGN.)
Signature for Consent to Treat *

Clear
Date

Month Day Year
Date

Acknowledgement of Receipt of Notice of Privacy Practices (HIPAA)

The undersigned acknowledges review of a copy of the currently effective Notice of Privacy Practices for Volunteers in Medicine. A copy of this signed and dated Acknowledgment shall be as effective as the original. The undersigned may request a copy of the Notice of Privacy Practices.
Signature acknowledgment of HIPAA

Clear
Date

Month Day Year
Date

Release Form for Health and Financial Information
I, First Name* Last Name* , give my consent for Volunteers in Medicine to release/receive any or all health/financial information from/and to other providers.

Signature* Date*
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	Name	Relationship	Date of Birth or Age
Household Member
Household Member
Household Member
Household Member
Household Member
Household Member
Household Member

Release Form for Health and Financial Information