Patient Application and Recertifications

  • Patient Application and Recertifications

    PLEASE READ WHAT DOCUMENTS ARE NEEDED BEFORE APPLING

  • To complete this application will need the following documents.Application will not be approved until we have all documents.

    • A valid picture ID (driver license, visa, passport, green card, state-issued ID card)

    • Proof of residency (rental lease, utility bill showing current address, notarized letter from landlord)

    • Proof of income (A wage inquiry from the Georgia Department of Labor this must be done in person this is one in Decatur 4572 Memorial Drive(EVERYONE needs to submit the wage inquiry)with 1 month of check stubs; or if check stubs are not available, a statement of gross amount received from your employer on company letterhead, if you receive Supplemental Security Income (SSI), an award letter with monthly amount is required.) If not working we need a support letter from the person helping you with the dollar amount .If you are a contract worker we need your 1099.
  • Are you a new patient applying or an existing patient who is recertifying their information? Please select the option below that applies to you.*
  • Have you been referred to Men's Clinic at Physician's Care Clinic by the DeKalb County Board of Health?*
  • How did you hear about Physicians' Care Clinic?*

  • Patient Contact Information

  • May we leave a voicemail, text, or email to contact you?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Patient Background Information

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  • Gender*
  • Ethnicity*
  • Race (Check all that apply)*
  • Primary Language*
  • Do you need an interpreter?*
  • Marital Status*
  • Sexual Orientation*
  • Current Living Situation*
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  • Are you a student?*
  • Are you a veteran?*
  • Do you work?*
  • Employment Status*
  • Format: (000) 000-0000.
  • Do you have any medical insurance?*
  • Do you have dental insurance?*
  • Do you have vision insurance?*

  • Patient Background Information Confirmation

  • Emergency Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Household Size and Income

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  • Acknowledgement of Receipt of Privacy Notice

  • Click here to view the Notice of Privacy and Confidentiality Practices Form & the Patient Rights & Responsibilities

    I acknowledge that I have received a copy of the Notice of Privacy Practices for the Physicians’ Care Clinic. I also acknowledge that I have been provided with an opportunity to ask questions and receive answers regarding the Notice and its contents.

  • Patient Medical History

    Please only select the allergies and medical conditions you have had.
  • Allergies
  • Childhood illness
  • Vision
  • Ear/Hearing
  • Sinus Problems
  • Lung
  • Heart/Vascular
  • Muscle/Bone/Joint
  • Infectious Disease
  • Gastrointestinal
  • Kidney/Urinary
  • Nervous System
  • Endocrine
  • Blood Disorders
  • Emotional
  • Have you ever seen a psychiatrist?*
  • Have you had a cough for more than 3 weeks?*
  • Have you had a TB skin test?*
  • If yes, have you been tested for TB?*
  • Do you drink caffeine?*
  • Do you have unexplained weight gain or loss?
  • Have you ever had a drug or alcohol addiction?
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  • Medical Release Agreement

  •  - -

  • I request and authorize Physicians’ Care Clinic 2675 N Decatur Road Decatur GA 30033 to release healthcare information for the patient named above to:    

    I request and authorize to release healthcare information for the patient above to: Physicians’ Care Clinic 2675 N Decatur Road Decatur GA 30033 (fax) 404 501 7199

    I request and authorize Physicians’ Care Clinic 2675 N Decatur Road Decatur GA 30033 to release healthcare information for the patient named above to the patient or the patient’s representative listed below:
     

    The request and authorization apply to:

    Healthcare information relating to the following treatment, condition, or dates:   

    • All healthcare information
    • Records only
    • Labs Results and X-ray/Radiology Reports
    • Consultant Notes
    • Other:  
  • I authorize the release of STD results, HIV/AIDs testing, whether negative or positive to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.*
  • I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above*

  • Patient Acknowledgment and Authorization for Treatment

  • In applying for treatment in the Physicians’ Care Clinic (PCC):

    1. I understand that the Physicians’ Care Clinic is a private not-for-profit all volunteer supported clinic. No government funds are received for patient care. The clinic operates through the generosity of private donors.
    2. I understand health care provided by PCC will be by volunteer staff and volunteer health care providers who; by appointment only; and only during regular clinic hours. I authorize the examination, diagnostic procedures, and treatment deemed necessary by the doctor(s), other health care professional(s) and whomever she/he may designate as assistants. I understand Physicians’ Care Clinic is staffed by volunteers (physicians, PAs, CNPs, pharmacists, nurses, students). I accept and consent to treatment and services based on this knowledge.

    3. I understand a $10 donation will be requested of me at each visit.

    4. I certify that all information provided to the clinic is true and accurate. I understand that falsification of any information contained on this form will result in my inability to receive health care at the Physicians’ Care Clinic.

    5. I certify that I do not have medical information of any kind.

    6. I authorize the clinic pharmacy to dispense my medication(s) in their choice of container (which may not be child resistant). I accept responsibility for keeping my medications(s) in a safe place and out of the reach of children.

    7. I give permission for PCC to (a) send my medical records to any physician to whom I may be referred to by PCC or (b) request records from any physician I have seen in the past.

    8. I understand that I need to re-qualify annually or any time my circumstances change. I acknowledge that failure to provide the Physicians’ Care Clinic with an update on changes may result in my inability to receive health care.

    9. I understand that if I miss a scheduled appointment (3) three times without giving the office a 24-hour notice, I will be subject to dismissal from the clinic.

    10. I understand the participation in this clinic is entirely voluntary and may be discontinued at any time by myself or Physicians’ Care Clinic.
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