test form pages

Social Security #
Preferred NATIVE HEALTH Provider*
Billing Address (street # or PO Box, city, state, zip)*
Street Address City State ZIP Code
Secondary Address (street # or PO Box, city, state, zip)
Street Address City State ZIP Code

(i.e. temporary/permanent)
Primary Phone Number*
Secondary Phone Number
Email*
Contact Preference
- Primary Phone
- Secondary Phone
- Email*
- Text*
May leave voicemail message
- Yes
- No

Demographic Information

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.
Ethnicity*
Not Hispanic Latino
Mexican/ Mexican American/ Chicano
Puerto Rican
Cuban
Other Hispanic
Chose not to Disclose Ethnicity
Decline to Specify Hispanic or Latin Origin
Race*
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Black/African American
American Indian Alaska Native
White
Choose not to disclose Race
Other
Specify:*

Federal Enrolled:*

Yes

No
Other

Primary Language*
English
Spanish
Other
Marital Status*
Married
Single
Divorced
Widowed
Separated
Partner
Sexual Orientation*
Lesbian/Gay/Homosexual
Bisexual
Straight/Heterosexual
Don't want to disclose
Don't know/ Questioning
Other
Other

Veteran*
Yes
No
What Branch*

Gender Identity*
Male
Female
Transgender Man
Transgender Female
Other
Choose Not to Disclose
Other*

Have you worked as a Migratory Agricultural Worker in the 24 months? If minor, has the minor’s parent/ guardian worked as Migratory Agricultural Worker?*

Yes

No
Were you employed to work with a specific seasonal agricultural products*

Yes

No
What is your housing status?*

Doubling Up with Other Friends or Family

Group home or Sober Living

Housed by Mental health or Substance Use Treatment Program

Incarcerated

Permanent Supportive Housing

Shelter

Stably Housed

Street

Temporary Supportive Housing/Transitional Housing
Employment
Occupation

Employer Name

Employer Address

Employer Phone Number
Approximate Total Annual Household Income
$0-$20,000
$21,000-$30,000
$31,000-$40,000
$41,000-$50,000
$51,000-$80,000
$81,000+
Number of People in your Household
1
2
3
4
5
6
7
8
9
10
Other
(includes spouse and children, under 18 years old)
Other

Insurance Information
Do you have health insurance?*

Yes

No (Skip to next Section)
Primary Plan Carrier Name

Primary Plan Carrier Phone Number
Policy #

Group #

Health Insurance Effective Date
MM slash DD slash YYYY

Policy Holder

Self

Other
Name of policyholder

Policyholder Date of Birth
MM slash DD slash YYYY

Do you have other insurance?

Yes

No (Skip to next section)
Secondary Plan Carrier Name

Secondary Plan Carrier Phone #
Secondary Policy #

Secondary Group #

Service Discount Program

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.
Would you like to apply for the Discount Program?*

Yes (Please see an FHA)

NO
Would you like to apply for the AHCCCS (AZ State Medicaid)?*

Yes (Please see an FHA)

NO
Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge I have received a copy of NATIVE HEALTH/NHW Community Health Center’s Notice of Privacy Practices.
Patient Signature:

Missed Appointments/Late Cancellations

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).
Consent to Film, Photograph and Record

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.
Consent for Treatment and Agreements of Financial Responsibility

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 companies, 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.
Patient/Legal Representative Signature:*

Date:*
MM slash DD slash YYYY

Print First Name:*

Print Last Name:*

For MINORS:
Patient Parent/Guardian Signature:

Date:
MM slash DD slash YYYY

Patient Parent/Guardian Print Name:

*For Guardians and Legal Representatives, please provide supporting documents that proves you are the patient’s guardian/Legal Representative.
Front Desk Representative Name:

Date:*
MM slash DD slash YYYY

New Patient Registration Form - Medical - tester

Step 1 of 7

If minors (under age 18) is the patient, please complete below - Guardians required to provide supporting document

Tribal Information

Demographic Information

Employment

Insurance Information

Service Discount Program

Acknowledgement of Receipt of Notice of Privacy Practices

Missed Appointments/Late Cancellations

Consent to Film, Photograph and Record

Consent for Treatment and Agreements of Financial Responsibility

For MINORS:

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