Patient Registration Form

Please Note: Before starting this form, please be sure you have approximately 10 minutes to complete. You cannot save your work and return later.

Patient Registration Form

How Did You Hear About Us?*
How did you hear about CHC?
Please Choose Your Preferred Medical Center*
Name*
Prefix First Middle Last
Email Address
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Work Phone
Cell Phone
Do you have a preference for a specific provider? If so, which one?
If your Primary Care Provider (PCP) is not CHC, please list the PCP/Practice name and Phone Number:
PCP Name
First Last
Practice Name
PCP Phone Number
Social Security Number*
Date of Birth*
Month
Day
Year
Gender Identity*
Sexual Orientation*
Marital Status*
Employment Status*
Employer Name (If Applicable)
Student Status*
Race*
Ethnicity*
Language*
Email Address*
What pharmacy do you use?*
Are you homeless?*
Are You Disabled?*
Are You a Veteran of Military Service?*
Do you have an Advanced Directive (living will, DNR, etc.)?*
Insurance Provider Name
Insurance ID Number
Insurance Group Number
Photo of Insurance Card
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.
Please upload a photo of your insurance card.
*PLEASE NOTE: YOU MUST BRING YOUR INSURANCE CARD TO YOUR APPOINTMENT
Emergency Contact
Name*
First Last
Phone*
Relationship to Patient*
Address*
Street Address Address Line 2 City State ZIP Code
Caregiver's Information (if applicable)
Name
First Last
Phone
Caregiver's Relationship
Certification
I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge.
Patient or Guardian Name*
First Last
Date*
Month
Day
Year
NOTICE OF AUTHORIZATIONS & ASSIGNMENT OF BENEFITS
Assignment of Insurance Benefits: I HEREBY AUTHORIZE DIRECT PAYMENT OF INSURANCE BENEFITS TO COMPASSION HEALTH CARE, INC. or the physician individually for services rendered to my dependents, or me, by the physician or those under his/her supervision. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any co-pay or balance due that Compassion Health Care, Inc. is unable to collect from my insurance carrier, for whatever reason.
Authorization to release non-public information: I certify that I have read and been offered a copy of the Compassion Health Care, Inc. “HIPAA Notice of Privacy Practices”, as well as receipt of Compassion Health Care, Inc.’s Office Practices and Patient Rights & Responsibilities. I hereby authorize Compassion Health Care, Inc. and/or the physician individually to release any of my or my dependent’s medical or incidental nonpublic personal information that may be necessary for medical evaluation, treatment, consultation, or the processing of insurance benefits. Compassion Health Care, Inc. reserves the right to revise its Notice of Policy Practices, Office Practices, and Patient Rights and Responsibilities at any time. A copy of such revisions will be available upon request.
Medicare/Medicaid Information: I certify that the information given by me in applying for payment under these programs is correct. I authorize the release of any of my or my dependent’s records that these programs may request. I hereby direct that payment of my or my dependent’s authorized benefits may be made directly to Compassion Health Care, Inc., or the physician on my behalf.
Lab Testing: I understand that I may receive a separate bill if my medical care includes lab services. I further understand that I am financially responsible for any co-pay or balances due for these services if they are not reimbursed by my insurance for whatever reason.
Prescriptions: I acknowledge that my treating physician/medical provider may obtain a prescription history if it is deemed necessary.
Consent to Treatment: I hereby consent to the evaluation, testing, and treatment as directed by my Compassion Health Care, Inc. physician or those under his/her supervision.
My signature below certifies that I have read and agree to all of the information stated above.
Name*
First Last
Date*
Month
Day
Year
Do you wish to enroll for access to your medical records via CHC’s patient portal?*
*Note: When you enroll, you will receive an email message at the address you gave us at the beginning of this form. You are strongly encouraged to use an email address that only you have access to.
PATIENT MEDICAL HISTORY INFORMATION
Please list all allergies, including medicines, foods, environmental and betadine:
Do you have, or have you had, any of the following health conditions?
Check all that apply
- Diabetes (Sugar)
- High Blood Pressure
- Asthma/Emphysema
- Heart Attack
- Heart Disease
- Stroke
- Tuberculosis
- Cancer
- Seizures
- Glaucoma
- Kidney Disease
- Kidney Stones
- Arthritis
- Osteoporosis
- Mental Illness
- Alcoholism
Check all that apply
- Hay Fever
- Pneumonia
- Broken Bones
- Phlebitis
- Skin Disease
- Gout
- Rheumatic Fever
- German Measles
- Chicken Pox
- Hepatitis
- Peptic Ulcer
- Vaginal Infection
- Sexually Transmitted Disease (STD)
- Anemia
- High Cholesterol
- Blood Transfusion
Other (Please Describe):
Have any family members had the following health problems?
- Diabetes (Sugar)
- High Blood Pressure
- Asthma/Emphysema
- Heart Attack
- Heart Disease
- High Cholesterol
- Stroke
- Tuberculosis
- Cancer
- Seizures
- Glaucoma
- Kidney Disease
- Kidney Stones
- Arthritis
- Osteoporosis
- Mental Illness
- Alcoholism
List the family member who has had any of the health problems.
Have you had any of the following surgeries?
- Tonsils/Throat
- Gall Bladder
- Bone
- Lung
- Tubal Ligation
- Thyroid
- Appendix
- Prostate
- Breast
- Ear
- Colon
- Circumcision
- Hysterectomy
- Eye
- Kidney
- Vasectomy
- C-Section
- Stomach
- Hernia
- Heart
- Ovaries
Other Surgery (Please Explain)
Social History (Please check all that apply)
- Alcohol Use (Any Type)
- Tobacco Use (Any Type)
- "Street" Drug Use (Any Type)
Female Patients Only
What year was your last delivery?
Period/Menstrual Cycle
First Day of Last Period
Month
Day
Year
Total # Pregnancies
Total # Live Births
Total # Miscarriages/Stillbirths
Total # Abortions
Please list all medications, including birth control and over-the-counter medications
Do you have any of the following symptoms or conditions? (Please check all that apply)
General Symptoms
- Fatigue
- Fever/Chills
- Headaches
- Loss of Appetite
Eyes
- Discharge
- Burning/Itching
- Eye Pain
- Loss/Blurred Vision
Ears, Nose & Throat
- Ear Pain
- Sinusitis
- Nasal Discharge
- Sore Throat
Cardiovascular
- Chest Pain at Rest
- Stress Pain During Strenuous Activities
- Shortness of Breath While Lying Down
- Swelling of Ankles
- Palpitations
Respiratory
- Coughing
- Wheezing
- Shortness of Breath
- Snoring
Gastrointestinal
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Blood in Stool
- Abdominal Pain
- Heartburn
Genitourinary
- Painful Urination
- Frequency Urination
- Blood in Urine
Musculoskeletal
- Back Pain
- Neck Pain
- Joint Pains
- Muscle Pain
Integumentary
- Skin Rashes
- Changes in Moles
Neurological
- Blackouts
- Tingling
- Paresthesia/Numbness
- Local Weakness
- Seizure Activity
Psychiatric
- Anxiety
- Depression
- Moodiness
Endocrine
- Excessive Thirst
- Change in Weight
Hematologic/Lymphatic
- Abnormal Bleeding
- Anemia
DISCLOSURE OF PROTECTED HEALTH INFORMATION
Patient Name*
First Last
Date of Birth*
Month
Day
Year
HIPAA (The Health Insurance Portability and Accountability Act) gives you the right to request that we communicate financial and/or medical information to you in confidence by a particular method. In order to protect the privacy and confidentiality of your information, please complete the following. This form will tell us how you wish to be contacted and with whom we may discuss your healthcare, insurance, and billing questions.
CHC may contact me at the following phone numbers:
Home
Cell
Work
CHC has my permission to leave a fully detailed message at:
- Home
- Cell
- Work
CHC has my permission to leave a ‘minimum necessary’ message at:
- Home
- Cell
- Work
This authorization permits the disclosure of protected health information that includes, but is not limited to, test results, diagnosis, treatment, and billing information. This information includes mental illness or developmental disability, psychotherapy notes, HIV/AIDS testing or treatment (including information regarding test order, performance, or results, regardless if the results were positive or negative), sexually transmitted disease, substance abuse, abused of an adult with a disability, sexual assault, child abuse or neglect, genetic testing.
I hereby authorize that the protected health information regarding the above-named person may be discussed with me or the following person(s):
Name
First Last
Relationship
Name
First Last
Relationship
CHC will continue to communicate with you according to your above response(s) until you change your preferences. We will continue to leave appointment confirmations on your primary phone number. You can make a change by completing a new form. By signing below, you grant permission to the communication outlined above.
Patient Name*
First Last
Date*
Month
Day
Year
Signature of Parent/Legal Guardian/Personal Representative (Required if patient is not legally authorized to sign this form).
First Last
Relationship to Patient
Financial Policy (Private Insurance and Self-Pay Patients)
Any healthcare insurance policy that you may have is a contract between you and your insurance company or employer. Compassion Health Care, Inc. (CHC) will assist you in obtaining payment from any healthcare insurance policy for medical services that you receive at any CHC location; however, you remain primarily responsible to pay for all medical services that you receive from us.
Patient Name*
First Last
Date of Birth*
Month
Day
Year
Who is financially responsible for the patient?
First Last
Relationship to Patient
Phone
Is the patient currently covered by insurance?
*Please remember to present the current insurance card(s) at every visit.
Insurance Carrier
Second Insurance Carrier
You are responsible for co-payments, coinsurance, and deductibles, depending upon the insurance coverage. We require that co-payment be made at the time of service as well as deductibles if they have not been met. You also remain responsible for any balances due to co-payment, coinsurance, and deductibles.
I agree
Payment is due when services are provided. At your office visit, if you are not able to pay the co-payment, we will be happy to reschedule your appointment when you are able to. If the patient is a child who is seen at CHC's School-Based Health Center, CHC staff will contact the responsible party by phone to collect payment for that day's services.
I agree
Compassion Health Care, Inc. accepts MasterCard, Visa, American Express, and Discover, as well as cash, money orders, and checks for your convenience. There is a service charge for any returned checks. You will be charged $25.00 service charge along with the amount of the returned check within five (5) business days.
I agree
In the event you receive a statement in the mail from us for payment, it is your responsibility to pay that amount promptly. After 60 days of nonpayment, you will receive a final payment request letter. You will then have 10 days to pay in full. If you cannot pay your bill, it is your responsibility to contact CHC’s Billing Department to discuss a payment plan. The CHC Billing Department can be reached at (336) 694-9331, Option 4.
I agree
By agreeing here, you acknowledge that you have been made aware that CHC offers a sliding fee discount program to patients who qualify based on family size and income.
I agree
I have read and understand the financial policy of Compassion Health Care, Inc. and agree to be bound by it. I understand that healthcare insurance does not cover all medical services and I understand my responsibilities with respect to healthcare insurance as explained above. I understand that I am ultimately responsible for payment for medical services provided to me or my dependent(s) by Compassion Health Care, Inc. I hereby grant Compassion Health Care, Inc. the right to bill and collect from my healthcare insurance plan for medical services provided to me or my dependent(s).
Name*
First Last
Date*
MM slash DD slash YYYY
Compassion Health Care, Inc. is a Federally Qualified Health Center. As such, we are required to report demographic and statistical data. This information requested below will help us better serve those who need assistance. Please be assured that your information is never reported on an individual basis and will only be included anonymously with our compiled data.
Please select your family household size and your annual income OR monthly income (you don't have to choose both).
Please Choose Whether You Wish to Enter Annual or Monthly Income*
Family Size*
Monthly Income*
Monthly Income*
Monthly Income*
Monthly Income*
Monthly Income*
Monthly Income*
Monthly Income*
Monthly Income*
Family Size*
Annual Income*
Annual Income*
Annual Income*
Annual Income*
Annual Income*
Annual Income*
Annual Income*
Annual Income*
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Please Note: Before starting this form, please be sure you have approximately 10 minutes to complete. You cannot save your work and return later.

Patient Registration Form

NOTICE OF AUTHORIZATIONS & ASSIGNMENT OF BENEFITS

PATIENT MEDICAL HISTORY INFORMATION

DISCLOSURE OF PROTECTED HEALTH INFORMATION

Financial Policy (Private Insurance and Self-Pay Patients)

Having trouble with this form?

Have a question? Call CHC now.

336-694-9331

Email Us.

info@compassionhealthcare.org

Provider Search

Please Note: Before starting this form, please be sure you have approximately 10 minutes to complete. You cannot save your work and return later.

Patient Registration Form

NOTICE OF AUTHORIZATIONS & ASSIGNMENT OF BENEFITS

PATIENT MEDICAL HISTORY INFORMATION

DISCLOSURE OF PROTECTED HEALTH INFORMATION

Financial Policy (Private Insurance and Self-Pay Patients)

Having trouble with this form?

Search