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  • Patient Application and Recertifications

  • To complete this application will need the following document ready:

    • 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 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.)
  • Patient Contact Information

  • Patient Background Information

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  • Patient Background Information Confirmation

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  • Emergency Contact Information

  • 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.

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  • Patient Medical History

    Please only select the allergies and medical conditions you have had.
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  • Medical Release Agreement

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  • 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:  
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  • 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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