By providing my e-mail address and phone number to Lackey Clinic, I permit the use of my e-mail and phone number to receive email and text communications.

1620 Old Williamsburg Road, Yorktown, VA 23690
Phone: (757) 886-0608     Fax: (757) 369-3821

AUTHORIZATION FOR USE OF PROTECTED HEALTH INFORMATION
Use and/or Disclosure of Medical Records 

1. INDIVIDUAL PATIENT (OR PERSONAL REPRESENTATIVE) CONFIRMING THE AUTHORIZATION

Patient's Name: {name}     

Date of Birth: {dateOf}     

Social Security Number: {socialSecurity8}

2. THE USE AND/OR DISCLOSURE AUTHORIZED

I give my authorization to    Lackey Clinic    to use or disclose my protected health information as described below. I give the authorization voluntarily. 

Individual or entity authorized to receive my health information:    Lackey Clinic   

Purpose for which disclosures are to be made:    Medical Diagnosis/Treatment   

3. ENDING THIS AUTHORIZATION AND/OR CHANGING YOUR MIND ABOUT THIS INFORMATION

I understand that I may inspect or request copies of any information disclosed by this authorization. It is my understanding that this authorization will expire in 60 days from the date signed below unless revoked earlier. I udnerstand that I may revoke this authroization by notifying, in writing, the Medical Records Department, knowing that previously disclosed information would not be subject to my revoke request. 

4. SIGNING THIS AUTHORIZATION IS NOT A CONDITION OF TREATMENT 

I understand that under most circumstances a health care provider may not condition treatment, payment, enrollment, or eligibility for benefits on my signing this authorization. I also understand that if the person(s) or entity(s) that receivers the information is a not a health care provider or health plan covered by federal privacy regulations, the information described above may be redisclosed and is no longer protected by these regulations. Therefore, I release Lackey Clinic, its employees, and my physician from all liability arising from this disclosure of my health information. 

5. Individual Patient's Signature 

I have had the chance to read and think about the content of this authorization form and I agree with all statements made in this authorization. I understand by signing this form, I am confirming my authorization for use and/or disclosure of the protected health infromation described in this form with the people and/or organization named in this form.

   Patient Attestation and Agreement

 

By electronically signing below: 

• I pledge all information provided to Lackey Clinic for the purpose of my patient application or recertification is true to the best of my knowledge. I understand this information may need to be verified and that withholding information or giving false information will make me ineligible for care. 
• I understand if my income changes or if I become insured, including through Medicaid or Medicare, I must notify the clinic of these changes immediately. I understand any falsification or witholding of information regarding income or insurance status will result in suspension or dismissal from the clinic. 
• I understand if I become or continue to be a Lackey Clinic Patient, I am responsible for renewing my Lackey Clinic Patient status. I understand I will not be able to receive care or medications if my Lackey Clinic Patient status is expired. 
• I understand if I become or continue to be a Lackey Clinic Patient, I am required to bring in my 1040 (tax statements) immediately after filing and will not wait until my next recertification.
• I consent to necessary treatment, laboratory test(s), and consultations recommended by my medical and/or dental team as needed for my health if I become or continue to be a Lackey Clinic Patient. 
• I authorize my medical and financial information to be shared with other health care providers, pharmaceutical companies, and RXPartnership, including their designees, as needed for audit or medical/dental treatment purposes if I become or continue to be a Lackey Clinic Patient.
• I understand if I become or continue to be a Lackey Clinic Medical Patient, additional documentation may be requested as needed when ordering medication.
• I authorize LMAP (Lackey Medication Assistance Program) caseworkers to become my advocate in ordering medications if I become or continue to be a Lackey Clinic Medical Patient. In doing so, I authorize them to sign the application forms and reorder medications as needed on my behalf. 
• I understand if I become or continue to be a Lackey Clinic Dental Only Patient,  I will only be eligible to be seen by the Lackey Clinic Dental Department. I understand that I am not eligible for medical services or medications provided by Lackey Clinic. 
• Disclaimer for Medicaid eligible patients: Please be advised, because of the restrictions given to us by other health care providers and pharmaceutical companies, patients who are currently uninsured but may be eligible for Medicaid may receive limited services. These services include but are not limited to: specialty care, surgeries, and certain medications.
• Disclaimer for undocumented patients: Please be advised, because of restrictions given to us by other health care providers and pharmaceutical companies, undocumented patients may receive limited services. These services include but are not limited to: specialty care, surgeries, and certain medications. [Le informamos que como consecuencia a las restricciones impuestas a los servicios provistos a pacientes indocumentados, por proveedores y compañías farmacéuticas, usted podrá recibir únicamente servicios limitados en la Clínica de Lackey. Estos servicios limitados incluyen pero no se limitan a, cuidados especiales, cirugía y solo ciertos medicamentos.]

In order to determine your eligibility, we need a driver's license (or other photo ID) and proof of income for everyone in your household. Please use the document upload or Take Photo button to attach your documents. You may also submit your application now and email your documents to enroll@lackeyhealthcare.org, fax them to 757-369-3821 (Attn: Eligibility), or drop them off during business hours.

Documents Needed: 

- Driver's License/Photo ID

     *If your ID/Driver's License does not have your current address listed, we will also need proof of address such as a utility bill, bank statement, or lease agreement

- Proof of Household Income 

     *Examples of proof of income: paystubs, W-2s, 1040 tax form & Schedule C (for those who are self-employment), social security award letter, disability award letter

If you are recertifying/applying to be a medical patient, we will also need your most recent 1040 tax form in order for you to be eligible to receive certain prescription medications