Patient Information and Consent

Photo ID
Drivers License or other Photo ID

Emergency Contacts
Emergency Contact (1)*
Phone Number*

Area CodePhone Number
Relationship*
Emergency Contact (2)
Phone Number

Area CodePhone Number
Relationship
Emergency Contact (3)
Phone Number

Area CodePhone Number
Relationship

Release of Information
The following individuals MAY BE TOLD about my personal health information, illness, and/or treatment. A minor’s (under age 18) health information may be discussed with their legal guardian without a signed authorization.

LEAVE BLANK IF NOT APPLICABLE
Name of Authorized (1)

First NameLast Name
Relationship to Patient (1)
Phone Number (1)
Please enter a valid phone number.
Name of Authorized (2)

First NameLast Name
Relationship to Patient (2)
Phone Number (2)
Please enter a valid phone number.
Name of Authorized (3)

First NameLast Name
Relationship to Patient (3)
Phone Number (3)
Please enter a valid phone number.

Medical Insurance Information
Name of PRIMARY Insurance Company
Primary Insurance Card (Front)
Primary Insurance Card (Back)
Guarantor's Name (Person responsible for billing)

First NameLast Name
Guarantors Date of Birth

MonthDayYear
Date
Guarantors Social Security Number
Policy number
Group number
Guarantors Address (if different than patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guarantors Phone (if different than patient)

Secondary Insurance

(SKIP IF NOT APPLICABLE)
Name of SECONDARY Insurance Company
SECONDARY Insurance Card (Front)
SECONDARY Insurance Card (Back)
Guarantor's Name (Person responsible for billing)

First NameLast Name
Guarantors Date of Birth

MonthDayYear
Date
Guarantors Social Security Number
Policy number
Group number
Guarantors Address (if different than patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guarantors Phone (if different than patient)

Household Information
Number of Household Dependents:
Gross Household Income: $
In an effort to ensure that payment of fees is not a barrier to care, Mainline Health Systems, Inc. offers those who need it a waiver of fees. All waiver requests will be specific to location and services approved, and are granted at Mainline's discretion.*

YES, I request a waiver of fees.NO, I do not request a waiver of fees. I understand all services may be billed directly to me including co-pays and deductibles for services rendered.

Patient Portal
Mainline Health Systems, Inc. provides a secure patient portal via the internet that is designed to enhance patient, provider, and care team communications to improve patient care and satisfaction.

It is the responsibility of the patient to keep unauthorized individuals from learning their passwords and allowing access to their email information or portal account. It is also the responsibility of the patient and/or guardian to notify Mainline Health Systems, Inc. of any email address changes. Mainline Health Systems, Inc. offers patient portal access to patients 18 years and older or to the legal guardian of a minor child. Mainline Health Systems, Inc. provides the patient portal as a courtesy to our valued patients. If abuse or negligent usage is suspected, Mainline Health Systems, Inc. reserves the right at our own discretion to terminate patient portal offering, suspend user access, or modify services offered through the patient portal.
I do wish to participate in the patient portal and therefore acknowledge and have read and fully understand the above agreement and certify that I am 18years or older or that I am the legal guardian of the minor patient.I do NOT wish to participate in the patient portal.
Please confirm eMail address if you do wish to participate
example@example.com

Informed Consent
Mainline Health Systems, Inc. is dedicated to providing primary care, dental and mental health services to all our patients. Because physical and emotional problems often go together, we at Mainline Health Systems, Inc. believe the best care is given when health care providers work together. Mainline Health Systems, Inc. patients may be referred to providers from other health care specialties within the MHSI team; members of the treatment team will share clinical information with each other as it is clinically necessary and relates to your treatment.

I hereby voluntarily consent to outpatient care encompassing routine diagnostic procedures, examination, integrated medical care, and dental treatment including (but not limited to) routine laboratory work (such as blood, urine and other studies), taking of X-ray, heart tracing, administration of medications prescribed by the provider, and/or behavioral health services. (a) I further consent to the performance of those diagnostic procedures, examinations and rendering of medical, dental, and/or behavioral health treatment by the medical, dental, and behavioral health staff, including nurses, assistants, hygienists, behaviorists and/or other staff as is necessary per provider judgment. (b) I understand, that if I am 18 years or older, I may consent for all health services; otherwise, my parent or legal guardian will need to consent for services. (c) I understand some services at Mainline Health Systems may involve the use of telemedicine equipment and interaction with providers who are not physically onsite for consultation. These sessions are transmitted via secure, dedicated high speed lines and are not videotaped or saved in any way. I understand that the information gathered is strictly used for treatment purpose at Mainline Health Systems and will be maintained in Mainline Health Systems records only.
Release of Information
(a) I authorize the clinic to release medical, dental, and behavioral health information to the third-party insurance carriers for the purposes of filing insurance claims related to my (his/her) care and understand that I may be billed for services rendered. (b) I further authorize the release of all health information about treatment here to my (his/her) doctor or any designated by me. (c) I further authorize the ability to view prescriptive history from external sources. (d) I further authorize the release of health information to federal and state governing entities for the purposes of required reporting.

I understand that this consent form will be valid and remain in effect as long as I (he/she) attend the clinic.

This form has been fully explained to me and I understand its contents.
Authorized Signature*

Clear
Name of Authorized Party if Not Patient

First NameLast Name
Relationship if Not Patient
Should be Empty:

Patient Information

Photo ID

Emergency Contacts

Release of Information

Medical Insurance Information

Secondary Insurance

Household Information

Patient Portal

Informed Consent

Release of Information