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.

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.

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.