* NATIVE HEALTH cannot guarantee the security of messages sent by email or text and by initialing here you consent to using email or text even with the risk that the messages may be intercepted and read by a third party. _______ (initial)
You have the right to at any time request that NATIVE HEALTH
communicate with you using alternative means or to alternative locations. Please ask for assistance if you are interested in changing your contact preferences.
If you are affiliated with a Native American Tribe, please complete this section. If you are not affiliated with a Native American Tribe skip this section and complete the next section.
Some of the following questions may be uncomfortable for you to answer, however, your honest answer to the following questions will assist NATIVE HEALTH in providing the best services to you as an individual qualify for resources that support the services we provide.
You may be eligible for a discount on the cost of your health care depending on your family size and gross annual income. Please speak to a Family Health Advocate (FHA) to apply for the Discount Program at NATIVE HEALTH. If you qualify, you can receive a reduced out-of-pocket cost.
I acknowledge I have received a copy of NATIVE HEALTH/NHW Community Health Center’s Notice of Privacy Practices.
It is very important for you to keep all scheduled appointments. If you are unable to keep an appointment, you must notify us as soon as possible so we can use those appointment times for other patients. Three missed appointments will result in a standby appointment status and may lead to a dismissal from our clinic unless under special circumstances (ie. health crisis, epidemic, global pandemic, etc).
By signing below, I consent to the filming, recording or photographing of me for the purposes of identification, treatment and for NATIVE HEALTH's internal operations, such as quality improvement and educating students and professionals. I understand I will not receive any compensation for any such films, recordings, or photographs.
By signing below I am authorizing and consenting to all care and treatment provided by NATIVE HEALTH/NHW
Community Health Center and its affiliated health care providers, which may include students, residents, volunteers and other trainees. Through this consent, I am authorizing all care, including medical care, dental care, radiologic and diagnostic examinations, laboratory procedures and tests, and general medical and behavioral health care services requested or ordered by my health care provider. I understand that I may refuse services from a student, resident or trainee.
I authorize NATIVE HEALTH/NHW Community Health Center to submit claims for services rendered to my health insurer(s), including, Medicare, Medicaid, or other insurance company, and assign benefits payable for my services to NATIVE HEALTH/NHW Community Health Center. I understand that unless I am covered by an insurer, including federal and state health care programs, I am responsible for and agree to pay all amounts not paid for by my insurer(s), including applicable coinsurance and/or deductible amounts. If my insurer pays me directly for services rendered by NATIVE HEALTH/NHW Community Health Center, I will provide NATIVE HEALTH/NHW Community Health Center with copies of the insurer’s “Explanation of Benefits” and forward all payments received from my insurer to NATIVE HEALTH/NHW Community Health Center immediately upon receipt.
By signing below, I agree that all of the information that I have provided above is true and accurate to the best of my knowledge, that I have read and understand this form and that all of my questions have been asked and answered. I have been provided a copy of the NATIVE HEALTH “Patient Rights and Responsibilities” and acknowledge I have the responsibility to be involved in my care. I am signing this consent form willingly and voluntarily.
*For Guardians and Legal Representatives, please provide supporting documents that proves you are the patient’s Guardian/Legal Representative.