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 or Guadalupe County, 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.
Which county do you live in?*

Comal CountyGuadalupe CountyOther
What health insurance do you have?

Private health insuranceMedicareMedicaidVANone
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*

MonthDayYear
Date
Name*

First NameLast Name
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Date of Birth*

MonthDayYear
Date
Social Security
Gender*
Marital Status*
How did you here about us?*

AdvertisingPrimary Care PhysicianSpecialist PhysicianWord of MouthVIM PatientHospitalInsurance CompanyOther
If other, explain.*
How do you identify yourself:*

AsianCaucasianBlackHispanicN/AOther
Church Affiliation (optional)
Language *

EnglishSpanishOther
Are you currently working?*

YesNo
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 may result in the loss of eligibility to receive clinic services.
Signature*

Clear
Date*

MonthDayYear
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 may 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 all of the medications I need.I understand that if I have 3 no-shows in 12 months I may 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 may be counted as a no-show and may 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 specialist outside of VIM, 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 may be discharged from VIM.I will bring ALL medications with me for my visit. If I am a diabetic, I will bring blood sugar meter and diabetic journal with me to every appointment.
Signature for Agreement for Patient Responsibility *

Clear
Date*

MonthDayYear
Date

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

I understand that services I receive from Volunteers in Medicine providers is free of charge.

I 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 PROFESSIONALS TO TREAT ME (IF PATIENT IS UNDER 18 YEARS OF AGE, PARENT MUST SIGN.)
Signature for Consent to Treat*

Clear
Date*

MonthDayYear
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*

MonthDayYear
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*
Should be Empty:

	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