New Patient Registration & Attestation Form

New Patient Registration & Attestation Form
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Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*
Social Security Number (SSN)
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cellphone*
Please enter a valid phone number.
Marital Status*
Ethnicity*
Race*
Are you a veteran?*

YesNo
Your Insurance Member ID
Name of Insurance
Your Insurance Group ID
Emergency Contact*

First NameLast Name
Relationship*
Emergency Contact Phone #*
Please enter a valid phone number.

Please list all related children who are under 18 years of age who are Alliance Community Healthcare patients

	Name	Date of Birth	Gender	Relationship to above individual	Insurance Card
Patient 1
Patient 2
Patient 3
Patient 4

Acceptance Required for the following*

ASSIGNMENT OF BENEFITS: I authorize payment of medical benefits to be sent directly to Alliance Community Healthcare, Inc., or its individual providers for services rendered for me and all my identified children under 18 years of age as listed above.
Acceptance Required for the following*

FINANCIAL AGREEMENT: I understand and agree that I am ultimately responsible for the balance for myself and all my identified children under 18 years of age as listed above for any professional services rendered. Should my insurance claim be denied for lack of eligibility or termination of coverage, I understand that I will be held responsible and intend to make payment for any balance due in those instances.
Acceptance Required for the following*

AUTHORIZATION OF TREATMENT: I hereby give permission to the staff of the Alliance Community Healthcare, Inc., to provide medical and dental treatment, vaccine administration, emergency treatment and/or other services. Routine testing for HIV (Human Immunodeficiency Virus), HCV (Hepatitis C) and/or HBV (Hepatitis B) may be performed. I authorize access to prescription information from Sure Scripts and/or release medical information for reimbursement purposes for myself and all my identified children under 18 years of age as listed above. I have received a copy of the PATIENT BILL OF RIGHTS, 24 HOUR ON-CALL POLICY, HEALTH CARE PROXY, LIVING WILL, PAIN MANAGEMENT, AND HIPAA NOTIFICATION
Sliding Fee Discount Program Eligibility*

I am not interested in disclosing my financial information; therefore, my family and I are not eligible for the sliding fee discount programAttached is my income documentation - tax records, pay stubs, employer letter, etc. (Please see attached Sliding Fee Application).I have no documentation to verify my income. (Please see attached Self-Declaration).
Patient/Legal Guardian/Caregiver Signature

Clear

Adult Consent & Acknowledgement of Services & ACH Policies

Completion of this consent is necessary to offer services to a patient. Some items may not apply to your current visit, however in order to provide comprehensive care during this visit and future visits we request that you complete this content entirely.
Acceptance Required*

I acknowledge that Alliance Community Healthcare has provided me with its Notice of HIPPA Joint Privacy and my Patient Bill of Rights in accordance with the NJ State Law.
Financial Agreement

The purpose of this financial agreement is to help Alliance patients understand about medical/dental insurance, eligibility, coverage, and our office policy and services.
It must be understood that:
- We render our services on the basis that insurance companies may or may not pay for all, or a portion of our charges
- Authorization for medical/dental treatment from your Insurance company does not guarantee full payment for the service
- Not all Insurance Companies/third party payors pay for all services, each policy has its own particular stipulations regarding covered services, or amount of coverage.
- All insurance companies state that verification of coverage is not a guarantee of coverage or payment. Actual benefits are determined by your insurance company after a claim is received
- Patients are personally responsible for knowing and understanding their own insurance policy, eligibility & coverage
- Patient are responsible for payment of outstanding deductibles and Co-Insurance amounts at time of service.
- Copayments will be collected at the time of service
- Patients are financially responsible for payments of all non-authorized procedures and non-covered services
- Changes in Insurance coverage must be reported to our staff promptly to avoid financial responsibility
Acceptance Required*

The patient or Patient’s Legal representatives hereby acknowledge that he/she is eligible for Health/Dental Insurance Benefits and Coverage/ That in the event of ineligibility for coverage of plan benefits, as well as non-authorized procedures and non-covered services. He/she understands and agrees to be fully financially responsible for payment of all costs incurred during the delivery of services and agrees to pay all charges to Alliance Community Healthcare.
NO SHOW/MISSED APPOINTMENT POLICY

To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their visit on time. If it is necessary to reschedule the appointment, please call us immediately at (201) 451-6300. A reminder call to you is made/attempted the day prior to your scheduled appointment. A minimum of 24 hours cancellation notice is required for appointments. If you do not cancel in advance, and do not present to the office for your appointment, this will be considered a “No-Show: appointment. If you incur 3 “No-Show/Missed” appointments within one year, you will be charged a $25.00 fee and no longer will you be able to schedule appointments in advance without a $25.00 pre-payment for the visit. We value you as a patient and will do everything we can to accommodate you, so that you don’t incur any no show charge please be courteous and call if you are unable to keep your scheduled appointment. Our goal is to provide quality medical care in a timely manner. In order to do so we have had to implement an appointment/cancellation policy. The policy enables us to better utilize available appointments for our patients in need of medical care.
Acceptance Required*

I have read and understand the Alliance Community Healthcare No-Show/Missed appointment Policy
Patient/Legal Guardian/Caregiver Signature

Clear

Sliding Fee Application

Qualifications for the sliding scale fee discount program are based on gross annual income and family size compared to the federal poverty levels. You are required to provide ACH with proof of income and a complete application prior to your second visit. If documentation is not provided by the second visits, the patient will be considered 100% self-pay. You must verify your income and family size at least annually or notify when changes occur if sooner. Payment of your nominal amount of flat rate is expected at the time of service. See ACH SFDP policy.
Sliding Fee Opt-out

I do not want the sliding fee

Apply for Sliding Fee Discount Program (SFDP)
The acceptable forms of proof of income are:
1. Most current tax returns or W-2, All 1099’s
2. Last two payroll check stub (gross income)
3. Social security earnings (or other retirement or VA benefits), including unemployment and child support, court orders, welfare checks, workman’s compensation checks, etc.
4. Letter from Employer/parent/caregiver if a patient does not file income tax returns and does not get paid with a check
5. Bank statement showing earnings deposited for one month.
6. Self declaration form (Self-declaration may only be used in special circumstances. Patients who are unable to provide written verification must provide a signed statement of income, and why (s) he is unable to provide independent verification).
Please note that the federal poverty levels change annually which may impact your eligibility for the sliding scale fee discounted program.
Name of Applicant*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cellphone*
Please enter a valid phone number.
Income Income will be defined as ALL sources and forms of revenue/earnings/funds (before taxes/gross/total income, e.g. line 22 of Form 1040/line 15 of Form 1040A/adjusted gross income line 4 of 1040EZ and Line 7 for 2022 redesigned 1040 (adjusted gross income or AGI)) (For Tax Year 2022, you will no longer use Form 1040A or Form 1040EZ) earned or received by an individual or family. Examples of income include but are not limited to: self-employment earning (net of business expenses), unemployment, gross employment earnings, tips, child support, alimony, interest, dividend, retirement/pension or social security income, student support income, welfare or other public assistance payments, veterans payments, survivor benefits, pension or retirement income, rental income, royalties, income from estate or trusts, educational assistance, assistance from outside the household, and other miscellaneous source, etc. Non cash benefits (such as food stamps and housing subsidies) do not count and income excludes capital gains or losses.

Family Size: Family members who are considered for the eligibility criteria for Sliding fee program include the following individuals who live in the same household:
- Patient, Spouse (including same sex marriage recognized by U.S. Jurisdiction)
- Children up to age 21, Elderly parents/relatives that are being supported by the same household.

Household Family Members*

	Name	Relationship	Date of Birth	Income Type (Source)	Annual Income $
1
2
3
4
5
6

Total annual income:*
Do you have any type of insurance that will cover all or a portion of your medical expense?*

YesNo
If yes, please list below and provide copy of insurance card to ACH Staff.
Insurance
Policy/ID Number
Insurance
Policy/ID Number
[It's mandatory to accept all the ACCEPTANCE clauses]
Acceptance Required*

I declare under penalty of perjury that the above information is true and correct, and I give Alliance Community Healthcare permission to investigate any information given in this application. I understand that this information will be kept in strict confidence. I also understand that if my income or “family size” should change, I am required to notify Alliance Community Healthcare on my next visit to the health center. All the members included above in your family size are automatically approved in ACH’s SFDP once you have been approved.

END
Please verify that you are human*
Should be Empty:

	I Do want	I Do not Want
Cardiac resuscitation
Mechanical respiration
Blood or blood products
Kidney dialysis
Antibiotics
Chemotherapy/radiation therapy
Simple diagnostic tests (blood work/x-rays)
Artificial or invasive forms of nutrition.
Artificial or invasive forms of hydration.
To become an organ donor

New Patient Registration & Attestation Form

Adult Consent & Acknowledgement of Services & ACH Policies

Financial Agreement

NO SHOW/MISSED APPOINTMENT POLICY

Advance Directive

Appointment of a Health Care Representative/Proxy

Healthcare Instructions Directive/Living Will

Sliding Fee Application