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  • Enrollment Application

    Enrollment Application

    Thanks for your interest in becoming a patient. If you need help, call us at 423-652-0260 ext. 272.
  • We're sorry, you cannot become a patient with Healing Hands Health Center

    We're sorry, you cannot become a patient with Healing Hands Health Center

    We cannot treat individuals whose primary residence is outside of Tennessee or Virginia.
  • To become a dental patient, we accept individuals who have no dental insurance OR who have Virginia Medicaid. We are currently NOT approved to be a TennCare Dental provider. If you have TennCare, you are welcome to apply to be a dental patient and we will put you on our TennCare Dental waitlist. Currently, we do NOT have an estimate on when we will be approved.

    To become a medical patient, we accept patients who have no medical insurance of any type including Virginia Medicaid and TennCare. We are currently not accepting new medical patients, but you may complete this application if you are already a medical patient and re-enrolling for another year of care.

  • Your IDENTIFICATION Information

    Your IDENTIFICATION Information

    Provide photo ID or other proof of identification.
  • I am weeks pregnant.

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  • Upload ID Image
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  • TIP:

    TIP:

    You can click the SAVE button at any time if you don't have the documents you need now. Once you have your documents you can complete this application.
  • Verify Your RESIDENCY.

    Verify Your RESIDENCY.

    Please select from the choices below
  • Your Address and Residency Verification

    Your Address and Residency Verification

    Please provide information and proof of your residency
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  • TIP:

    TIP:

    You can click the SAVE button at any time if you don't have the documents you need now. Once you have your documents you can complete this application.
  • Consent to Share Healthcare Information

    Consent to Share Healthcare Information

    In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information. The individual is also provided the right to request confidential communication or that communication be made by alternate means, such as sending correspondence to the individual’s office instead of the individual’s home.

  • I authorize Healing Hands Health Center to release my healthcare information to the person(s) listed below. I understand that the person(s) named on this authorization will be given access to obtain results/information on my behalf. I authorize the person(s) indicated to pick-up materials pertinent to my
    medical care.

  •             Relationship to you .

  •             Relationship to you .

  •             Relationship to you .

  • Clear
  • Information About You.

    Information About You.

    Please provide more information about you. When you have completed this section



  • When you have completed this section, please click NEXT to continue.
  • Determining the Number in Your Household

    Determining the Number in Your Household

    We define your household as YOU, a spouse, and any dependents (those individuals you do or would list on your tax return), if applicable.
  • Your Household Income: The APPLICANT (You)

    Your Household Income: The APPLICANT (You)

    Please provide the information below to help us determine your household income. You must provide proof of income for all dependents in your household.
  • Upload your weekly pay stubs for the past 30 days

    Upload your weekly pay stubs for the past 30 days

    Please upload images or scans of your pay stubs. If you paychecks are direct deposited into your account, upload your electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Upload your bi-weekly pay stubs for the past 30 days

    Upload your bi-weekly pay stubs for the past 30 days

    Please upload images or scans of your pay stubs. If you paychecks are direct deposited into your account, upload your electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Upload last month's pay stub

    Upload last month's pay stub

    Please upload images or scans of your pay stubs. If you paychecks are direct deposited into your account, upload your electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Self Employment Income

    Self Employment Income

  •  
  • I   *   *, do hereby certify that all the above income information for the past 3 months is true and correct.

    *   
    Pick a Date*   

  • Need Employer to Verify Income

    Need Employer to Verify Income

    Your employer need to fill out the Employee Payroll Verification form. Continue with the application and we will send you the form after your application is submitted.
  • Receiving Unemployment

    Receiving Unemployment

    Please upload the most current official unemployment benefit letter that shows the amount you are receiving.
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  • When you have completed this section, please click NEXT to continue.
  • Receiving Other Benefits

    Receiving Other Benefits

    You are seeing this section because you indicated you were receiving income from other state, federal or court mandated sources (Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefit or periodic allowances such as alimony, or child support). Please upload the official letters from each source showing the amount of benefit income you are receiving.
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  • When you have completed this section, please click NEXT to continue.
  • No Income Certification

    No Income Certification

    You are seeing this section because you indicated you are not currently not making any income of any type.
  • I,   *   *  , certify that I do not receive income from any of the following sources: 

    • Wages from employment (including commissions, tips, bonuses, etc.); 
    • Rental income from real or personal property; 
    • Interest or dividends from assets; 
    • Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefits; 
    • Unemployment
    • Periodic allowances such as alimony, child support. 

     

    Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge.


    *   

    Pick a Date*   


    When you have completed this section click NEXT to continue.

  • TIP:

    TIP:

    You can click the SAVE button at any time if you don't have the documents you need now. Once you have your documents you can complete this application.
  • Household Income: Your SPOUSE/Legal Partner

    Household Income: Your SPOUSE/Legal Partner

    You are seeing this section because you indicated that you are married (you are not required to submit income for a spouse from whom you are legally separated) You must provide proof of income for your spouse/legal partner in your household.
  • Upload your weekly pay stubs for the past 30 days

    Upload your weekly pay stubs for the past 30 days

    Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Upload your bi-weekly pay stubs for the past 30 days

    Upload your bi-weekly pay stubs for the past 30 days

    Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Upload last month's pay stub

    Upload last month's pay stub

    Please upload images or scans of their pay stubs. If paychecks are direct deposited into your account, upload the electronic pay stubs. NOTE: Back statements are not considered acceptable proof of income.
  • Self Employment Income

    Self Employment Income

  •  
  • I       (spouse/legal partner), do hereby certify that all the above income information for the past 3 months is true and correct.

       Spouse/Legal Partner
    Pick a Date   

  • When you have successfully completed this section, please click NEXT to continue.
  • Need Employer to Verify Income

    Need Employer to Verify Income

    The employer need to fill out the Employee Payroll Verification form. Continue with the application and we will send you the form after this application is submitted.
  • Receiving Unemployment

    Receiving Unemployment

    Please upload the most current official unemployment benefit letter that shows the amount they are receiving.
  • Browse Files
    Cancelof
  • When you have completed this section, please click NEXT to continue.
  • Receiving Other Benefits

    Receiving Other Benefits

    You are seeing this section because you indicated your SPOUSE/Legal partner is receiving income from other state, federal or court mandated sources (Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefit or periodic allowances such as alimony, or child support). Please upload the official letters from each source showing the amount of benefit income being received.
  • Browse Files
    Cancelof
  • When you have completed this section, please click NEXT to continue.
  • No Income Certification

    No Income Certification

    You are seeing this section because you indicated your SPOUSE/Legal Partner is currently not making any income of any type.
  • I,        (SPOUSE/Legal Partner), certify that I do not receive income from any of the following sources: 

    • Wages from employment (including commissions, tips, bonuses, etc.); 
    • Rental income from real or personal property; 
    • Interest or dividends from assets; 
    • Social Security payments, such as Supplemental Security Income, Social Security Disability Income, Retirement, Survivor’s Benefits, annuities, insurance policies, pensions, or death benefits; 
    • Unemployment
    • Periodic allowances such as alimony, child support. 

     

    Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge.


       SPOUSE/Legal Partner

    Pick a Date   


    When you have completed this section click NEXT to continue.

  • TIP:

    TIP:

    You can click the SAVE button at any time if you don't have the documents you need now. Once you have your documents you can complete this application.
  • Your Emergency Contact Information

    Your Emergency Contact Information

    The person we should call in the event of an emergency.

  • PHARMACY: Supplemental Documents and Terms and Conditions

    PHARMACY: Supplemental Documents and Terms and Conditions

    The documents requested below are NOT necessary to become a patient, but it will help the medical clinic at Healing Hands provide you with reduced cost medications. Please read, acknowledge, sign, and date the below terms and conditions.
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  • *   
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  • How did you hear about us?

    How did you hear about us?

  • Clinic Guidelines

    Clinic Guidelines

  • To provide you with the quality care you deserve, we ask that you do your part by agreeing to the following clinic guidelines.

    Patient Care:

    • Various volunteer physicians, dentists, specialists, nurses, dental assistants, medical assistants, hygienists, and students in training will be providing your care.
    • Pre-doctoral or pre-hygienist clinic treatment is performed by student doctors and student hygienists under the direct supervision of an experienced University of Tennessee faculty dentist and ETSU faculty
      physician or hygienist.
    • Treating any provider with disrespect will result in an immediate dismissal from the program.

    Appointment Policy:

    • A No-Show/Missed Appointment fee will be administered to patients who do not cancel their appointments within 24 hours prior to the given appointment time.
    • The No‐Show fee will be $50 for missed dental appointments and $25 for all other missed appointments including medical, dental hygiene, vision, and referrals to outside providers.
    • We will attempt to contact you to remind you of your appointment time.
    • It is your responsibility to provide our clinic with a working phone number and to update us with any new telephone numbers.
    • If we cannot reach you to confirm your appointment and you do not call 24 hours prior to your appointment to confirm, your appointment will be given to the next deserving patient in need, and you will be responsible for the no show/missed appointment fee.
    • Patients who miss scheduled appointments will not be seen in the clinic again until the no‐show penalty fee is paid in full.
    • You may not bring an unsupervised child with you to your appointment. Please make childcare arrangements or the appointment will be canceled, and you will be charged a no‐show fee.

    Patient Responsibilities:

    • I understand that if I am a medical patient who needs medication assistance or Project Access, I may be asked to provide more information.
    • I understand that I am responsible for any bills that may result from referrals to specialists or visits to the emergency room, urgent care, etc. I authorize Healing Hands Health Center to release the necessary medical records needed for any referral.
    • I understand that if I give false information to any representative of Healing Hands Health Center, I will be dismissed from the clinic.
    • We understand that having a health/dental issue is stressful, but all staff and volunteers are to be treated with respect, in person and phone calls.  Failure to do so will result in your dismissal from the clinic; this includes, but not limited to foul language, threats, shouting, etc.
    • Healing Hands does not provide narcotic pain management. We do not keep narcotics on the premises.
    • I agree to update my income documentation every year.
    • I agree to update my address and phone number when it changes.
    • You must advise the staff if you have any dental or medical insurance.
    • Arrive on time to your appointments. Arriving 15 minutes or more late for your appointment may result in your appointment being rescheduled. As a courtesy, you may receive a reminder call, but not always. It depends on our staffing and the volume of patients. It is your responsibility to keep track of your appointments.
    • Give a 24-hour notice for cancelling appointments. Failure to do so will result in a “No Show” fee that will have to be paid before scheduling another appointment.
    • The value for a standard patient visit to serve your healthcare needs is $140. We charge our patients a small fee so we can continue to meet the expanding needs of our community. I understand that the following patient fees are due at the time of my visit:

                 Medical $25
                 Eyeglasses $25
                 Dental $50
                 Other Dental Procedures $100
                 Eye Exam $20
                 Dental Hygiene $25
                 Medication Admin Fee $5/medication ($35 cap/visit)

  • Release:

    • I give permission for my photo, interview, and/or comments to be used for marketing and fundraising purposes.
    • I give permission for my x-rays or photos to be sent to other agencies associated with Healing Hands and/or to private doctors.

    I certify that I have completely read the clinic guidelines above. I understand each statement and agree to follow these guidelines.

  • Clear
  • Patient Disclosure and Consent

    Patient Disclosure and Consent

    Please read, sign, and submit your completed application.
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