Patient Registration Form

We do not discriminate against any person on the basis of race, color, national origin, sex, age, religion, or disability, in our programs and services

Patient Information
Please provide your photo ID to the Receptionist

Last Name: First Name:

Date of Birth: SSN: Primary Language:
Gender: Male Female Transgendered: Yes
Mailing
Address:
Physical
Address:
Home Phone: Work Phone: ext:
Cell Phone: E-mail Address:
We may contact you through the above communication methods for appointment and general health reminders unless you indicate a
method(s) you prefer we not use:
Marital Status: Single Married Partner Divorced Legally Separated Widowed Unknown
Race: White (includes Hispanic or Latino) Black or African American American Indian / Alaska
- Check all
that apply Asian Native Hawaiian Other Pacific Islander
Ethnicity: Hispanic / Latino Not Hispanic / Latino
Insurance or Payment Source
Please provide your Insurance Card(s) to the Receptionist

Medicaid CHIP Medicare Private Pay (self-pay) Other

Commercial Insurance Medicare with Supplement Insurance
- Name of Insurance: - Name of Insurance:

Employment Status
Full-time Self Employed Retired Active Duty Military
Part-time Not Employed Veteran
Responsible Party
Self (patient listed above )
Guarantor; please complete the following details:
Last Name: First Name:
Date of Birth: Relationship to patient:

Address:

Best Contact Telephone Number: Home Cell Work

Emergency Contact
Last Name: First Name:
Home Phone: Work Phone: ext:
Cell Phone: Relationship to patient:
Preferred Pharmacy:
Pharmacy Name:
Address:

I acknowledge my responsibility to pay for services rendered and understand that I will be responsible for any fees that
are not paid by my Insurance or covered by HealthPoint programs.
Please initial
 GENERAL CONSENT FOR TREATMENT
The information in this consent form outlines your Additionally, limited information may be released to
rights, as our patient, to be informed about your certain Federal and State agencies that provide
condition and the recommended medical or funding to HealthPoint in order to ensure compliance
diagnostic procedures your provider may use with legal responsibilities.
throughout the course of your relationship with
HealthPoint. I understand that HealthPoint is a federally deemed
facility under the Federal Torts Claims Act, meaning
that HealthPoint is considered a part of the federal
I, ________________________________________, government for the purposes of civil liability.
(PATIENT’S PRINTED NAME)
This consent will remain in effect until I withdraw my
born on ______ _/_________/_________________, consent. If HealthPoint changes the nature of its
(PATIENT’S DATE OF BIRTH) services, or it has been at least two years since my last
consent to and request that my health care provider, appointment, I will be asked complete another general
along with any necessary staff, perform reasonable consent for treatment.
and necessary medical examinations, tests, and
treatments for the purpose of assessing and managing I have been given the opportunity to ask questions
any conditions or illnesses that I currently have or regarding this consent, and I certify that this form has
may develop. been fully explained to me and that I understand its
contents.
I understand that HealthPoint is a primary care clinic
that focuses on preventative healthcare. I
acknowledge that only a limited number of these ______________________________________________
primary care examinations, tests, or treatments require SIGNATURE OF PATIENT OR OTHER LEGALLY
disclosure of specific risks, as required by the Texas AUTHORIZED PERSON
Medical Disclosure Panel; should my health care
provider recommend a treatment that requires
______________________________________________
disclosure of specific risks, I will be asked to sign NAME OF OTHER LEGALLY AUTHORIZED PERSON
additional documents indicating that I have been (if applicable)
advised of the specific risks and hazards of the
recommended procedure or treatment.
______________________________________________
I understand there are certain risks or hazards RELATIONSHIP OF OTHER LEGALLY AUTHORIZED
associated with any form of treatment or test, and that PERSON TO PATIENT (if applicable)
I have not been made any guarantee about a result or
cure from any treatment or test provided by
HealthPoint or its staff. I further acknowledge that ____________/_____________/____________________
TODAY’S DATE
HealthPoint does not assume any responsibility,
financial or otherwise, for services or care received
outside of HealthPoint.

I acknowledge that minimally necessary information

may be released by HealthPoint in order to comply
with Federal and State law, including the Health
Insurance Portability and Accountability Act of 1996
and the Texas Medical Records Privacy Act.

Created: 12/19/2018
Revised: 12/19/2018
 Third Party Information Release & Consent
Please read this entire form before signing and complete all sections that apply to your decisions relating to the disclosure of protected health
information (PHI). This clinic is required by federal and state law to obtain a signed authorization from the patient (or patient’s legally authorized
representative) to disclose that patient’s PHI. As indicated below, specific authorization is required for the release of information about certain sensitive
conditions, including: mental health records; drug alcohol, or substance abuse records; records relating to HIV/AIDS; genetic (inherited) diseases or tests).
This form is NOT required for the permissible disclosure of an individual’s PHI to themselves or the patient’s legally authorized representative. However,
such access may be limited by physician or mental health provider if determined to be harmful to the patient’s physical, mental, or emotional health.

EFFECTIVE TIME PERIOD. This authorization is valid until either the occurrence of the death of the patient or permission is withdrawn.

RIGHT TO REVOKE. One can withdraw permission at any time by giving written notice revoking this authorization to the person or organization named
herein.

SIGNATURE OF PATIENT OR AUTHORIZED INDIVIDUAL

DATE _________________________________ ACCOUNT NUMBER_________________________________

SIGNATURE AUTHORIZATION. I have read this form and agree to the uses and disclosures of the information as described. I understand that information
disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.

I authorize the BRAZOS VALLEY COMMUNITY ACTION AGENCY, INC. dba HEALTHPOINT to disclose my protected health
information to the following individual/organization:

Individual/Organization Name ________________________________________________________________________

Address __________________________________________________________________________________________

City _______________________________________________________ State _____________ Zip Code ____________

Phone (______)______________________________ Fax (______)_______________________________________

WHAT INFORMATION CAN BE DISCLOSED TO THIS INDIVIDUAL/ORGANIZATION? (Check all that apply):
□ ALL HEALTH INFORMATION □ History /Exams/Progress Notes □ Lab results

□ Reports & Images □ Medications & Allergies □ Physician’s orders

□ Billing information □ Appointment information □ Other _____________

Your initials are required to release the following information:

________Mental health records (excluding psychotherapy notes) ________Genetic information (including genetic test results)

________Drug, alcohol, or substance abuse records ________HIV/AIDS test results/treatment

Complete the following section ONLY IF THE PATIENT IS A MINOR (i.e., under the age of 18) or a LEGALLY NON-COMPETENT adult AND
you are the parent/legal guardian of the patient:
Does the above-listed, non-parent individual/organization have authorization to consent to medical treatment (immunization excepted)
for the patient?
If YES, please initial in the following blank: __________
 PATIENT AND CENTER RIGHTS AND RESPONSIBILITIES

Patient’s Name: __________________________ You have the right to receive a complete

discussion of your privacy rights as our patient in
Date of Birth: ________/________/___________ the form of our “Notice of Patient Privacy
Rights”; this document provides a
comprehensive review of the ways in which we
Welcome to HealthPoint may use or disclose your medical records. By
signing the “Patient and Center Rights and
Our goal is to provide the highest quality health Responsibilities” you are acknowledging that
care that is both affordable and accessible to all. you have received and understood our “Notice of
As a patient, you have rights and responsibilities. Patient Privacy Rights.”
The center also has rights and responsibilities.
We want you to understand these rights and • Health Care
responsibilities so you can help us provide better You have the right, and are encouraged, to
health care for you. Please read and sign this participate in decisions about your treatment.
statement and ask us questions you might have.
You have the right to information about your
Your Rights as Our Patient health or illness, and your treatment plan,
including: the nature of your treatment; its
• Nondiscrimination expected benefits; its inherent risks and hazards
You have the right to be treated with respect (and the consequences of refusing treatment); the
regardless of race, color, marital status, religion, reasonable alternatives, if any (and their risks and
sex, national origin, ancestry, physical or mental benefits); and the expected outcome, if known.
handicap or disability, age, veteran status, or After being informed of this information and
other grounds, as provided by federal, state, and providing your consent, you are giving us what is
local laws or regulations. known as “informed consent.”

• Payment You have the right to information and

While all patients of federally qualified health explanations in the language you normally speak
centers are expected to financially participate in and in words that you understand.
their health visits, you will not be denied services
due to an inability to pay at the time of the visit. You have the right to receive information
The clinic can assist you by screening you for regarding “Advance Directives.” If you do not
eligibility to participate in various state and wish to receive this information, or if it is not
federal programs that pay for some or all of your medically advisable to share that information
health visits, as well as providing options for with you, we will provide it to your legally
payment plans. authorized representative.

You have the right to receive explanations about If you are an adult, you have the right to refuse
the bill you received from the clinic. treatment or procedures to the extent permitted
by applicable laws and regulations. You have the
• Privacy right to be informed of the risks, hazards, and
You have the right for your interviews, consequences of your refusing such treatment or
examinations, and treatment to be conducted in procedures. Your receipt of this information is
privacy. Your medical records are also private. necessary so that your refusal will be “informed.”

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You have the right to health care and treatment Your Responsibilities as Our Patient
that is reasonable for your condition and within
our capability. However, the center is not an • Payment
emergency care facility. You have a right to be You have the responsibility to give staff accurate
transferred or referred to another facility for information about your present insurance and/or
services that the center cannot provide. The financial status, as well as any changes in your
center does not pay for services that you receive insurance and/or financial status. The staff need
from another healthcare provider. this information to determine your financial
responsibility and/or so they can bill private
If you are in pain, you have the right to receive insurance, Medicaid, Medicare, or determine
an appropriate assessment and pain management, other benefits for which you may be eligible. If
as necessary. your income is less than the federal poverty
guidelines, you will be charged a nominal fee.
• Center Rules
You have the right to receive information on how You have the responsibility to pay, or arrange to
to appropriately use the center’s services. If you pay, all agreed fees for medical and dental
have any questions, please ask us. services. If you cannot pay right away, please let
staff know so arrangements can be made.
If the center decides that we must stop treating
you as a patient, you have the right to advance • Privacy
written notice that explains the reason for the You have the responsibility of informing us of the
decision, and you will be given thirty (30) days people, if any, that may or may not access your
to find another primary care provider. medical records. It is important that we know this
information from the beginning of your
You have the right to receive a copy of the relationship with us so that we can avoid any
center’s “Noncompliance and Termination” future confusion. Staff can provide you a form to
Policy and Procedure. indicate those people you are granting access to
your private medical record.
If the center has given you notice of termination,
you have the right to appeal the decision to the If you are a parent or legal guardian, please let
Medical Director. staff know if someone other than yourself or the
child’s legal guardian may be bringing the child
• Complaints to receive services.
You have the right to tell us how we can improve
the services that we offer you. Staff will tell you • Health Care
how to make a suggestion or file a complaint. If You have the responsibility for providing the
you are not satisfied with how the staff handles center complete and current information about
your situation, you may contact the center’s your health or illness, so that we can give you
administration. proper health care.

Although we encourage you to bring your You have the responsibility for assuming the
concerns directly to us, you always have the right consequences and outcomes of refusing
to take any complaint to the Texas Department of recommended treatment or procedures. If you
State Health Services or Health and Human refuse treatment or procedures that your
Services. healthcare providers believe is in your best
interest, you may be asked to sign the center’s
“Patient Declination of Care” form.

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Created: 12/19/2018
Revised: 12/19/2018
You are responsible for appropriate use of center • Center Rules
services, which includes following staff HealthPoint has the right to stop treating you as a
instructions, and making and keeping scheduled patient if you commit a substantial violation of
appointments. Center professionals may not be the center’s rules.
able to see you unless you have an appointment.
HealthPoint has the right terminate its
• Center Rules relationship to you immediately and without
You have the responsibility to use the center’s written warning if you create a threat to the safety
services in an appropriate manner – this means of the center’s staff or other patients.
you must conduct yourself respectfully to all staff
and fellow patients at all times while you are HealthPoint’s Responsibilities as Your
accessing clinical services. Threatening, abusive, Provider
violent, fraudulent, intentionally offensive, or
any unlawful behavior will not be tolerated. If • Generally
your behavior is deemed to consistently or HealthPoint has the responsibility to ensure that
permanently disrupt the relationship between you are provided with quality care in an
your healthcare provider and yourself, then your environment that protects and promotes your
relationship to the center may be terminated rights as our patient.
pursuant to the center’s policies and procedures.
• Complaints
You have the responsibility to supervise the HealthPoint has the responsibility to ensure that
children that you bring with you to the center. no center representative will punish,
discriminate, or retaliate against you for filing a
You have the responsibility for your children’s complaint, and the center will continue to provide
safety, and the protection of other patients and you services.
our property.

You have the responsibility to keep your _____________________________________________

scheduled appointments. Missing scheduled SIGNATURE OF PATIENT OR OTHER LEGALLY
appointments causes delay in treating other AUTHORIZED PERSON
patients. If you do not keep scheduled
appointments and/or fail to provide timely _____________________________________________
notification to the center, pursuant to the center’s NAME OF OTHER LEGALLY AUTHORIZED PERSON
policies and procedures you may lose the (if applicable)
privilege to schedule future appointments.

HealthPoint’s Rights as Your Provider _____________________________________________

RELATIONSHIP OF OTHER LEGALLY AUTHORIZED
PERSON TO PATIENT (if applicable)
• Privacy
In certain instances, HealthPoint may be required
to disclose your medical records to State or ____________/_____________/__________________
Federal agencies for the purposes of mandatory TODAY’S DATE
reporting or investigations.

The center may also be compelled to disclose

your medical records pursuant to a valid court
order.

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Created: 12/19/2018
Revised: 12/19/2018