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New Patient Telehealth Enrollment (Age 18+)

Please complete all sections of this form if you are age 18 or older and are not an established patient with SICHC. 

New Patient Telehealth Enrollment Form (Age 18+)

Name(Required)
MM slash DD slash YYYY
Address(Required)
For access health records 24 hours a day, 7 days a week
Ethnicity(Required)
Race(Required)
Language Spoken(Required)
Marital Status(Required)
Gender(Required)

Employer Information

Billing Address(Required)
For Billing Questions

Primary Insurance

Do you have Medical Insurance(Required)
MM slash DD slash YYYY

Secondary Insurance

Do You Have Secondary Insurance(Required)
MM slash DD slash YYYY
Emergency Contact Person
Name
Relationship
Phone
 
Note - Click on the plus "+" icon to the right to add a new Contact Person.

Assignment and Release

I, the undersigned, have insurance coverage with the insurance company(ies) indicated above and assign directly to SICHC all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the provider to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submission.
Name
My name typed in the answer space to this statement serves as my electronic signature.
MM slash DD slash YYYY

Medicare Authorization

I request that payment of authorized benefits be made either to me or on my behalf to SICHC for any services furnished to me by my physician/nurse practitioner.
I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to the related services.
I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare assigned cases, the physician/nurse practitioner agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.

Name
My name typed in the answer space to this statement serves as my electronic signature
MM slash DD slash YYYY

Social History / Income Assistance

The following questions may seem difficult to answer, but are important for us to know, so we can properly screen all our patients for their health care needs. Additionally, we have many programs to provide financial assistance and appreciated your answers to these questions.

Are you a seasonal worker?(Required)
Are you a migrant worker?(Required)
Are you a Veteran?(Required)
Are you a homeless?(Required)
Do you live in public housing (housing provided for people with low income)?(Required)
Household Size(Required)
Yearly household income(Required)
Does you insurance pay for prescriptions?(Required)
What is your sexual orientation?

Medical History and Medications

Have you ever been diagnosed with any of the following (check all that apply):
Please list all medications including over the counter and supplements or vitamins(Required)
Medication
Dose
Frequency
 
Note - Click on the plus "+" icon to the right to add a new medication.
Have you ever been hospitalized or had surgery?(Required)
Please describe any hospitalizations or surgical procedures you have had
Name of Hospital or Surgery Center
Type of Hospitalization
Procedure
Date (month/year)
 
Note - Click on the plus "+" icon to the right to add a new listing.
Do you have allergies?(Required)
Please list all allergies to medications, foods, or environmental substances you have andt he reactions caused by those allergens.
Allergen
Reaction to Allergen
 
Note - Click on the plus "+" icon to the right to add a new listing.
Do you exercise?(Required)
Please list the type(s) of exercise you do and how often you do them.
Type of Exercise
How often do you exercise
 
Note - Click on the plus "+" icon to the right to add a new listing.
Do you smoke or vape?(Required)
If yes, how much and how often do you smoke or vape?
Smoke / Vape?
How often?
 
Are you a former smoker?(Required)
Do you use drugs?(Required)
If yes, how much and how often do you do drugs?
Drugs
How often?
 
Are you a former drug user?(Required)
Do you drink alcohol?(Required)
Are you a caffeine user?(Required)

Immunization History and Exposure

Please list the last date you had each of the following immunizations.(Required)
Influenza
Pneumovax
Tetanus
Shingles
COVID-19
 
Note - Click on the plus "+" icon to the right to add a new listing.
Have you traveled to another country within the last year?(Required)
If you have traveled outside the country, list the place(s) and dates traveled
Country
Date Travelled
 
Note - Click on the plus "+" icon to the right to add a new listing.

Female History

Have you ever had an abnormal pap or gynecological exam?
Have you had a hysterectomy?

General Health Maintenance and Planning

Have you ever had an abnormal colonoscopy?
Do you have a living will?(Required)
Do you have a durable power of attorney?(Required)
Would you like information on creating a living will?(Required)

Family Medical History

Please check the box that corresponds to the condition and the family member with that condition.

Mother
Father
Brother(s)
Sister(s)
Maternal Grand Parents
Paternal Grand Parents

Please list any health care providers including dentists, gynecologists, cardiologists, optometrists, etc. that you have:(Required)
Name
Specialty
Location
 
Note - Click on the plus "+" icon to the right to add a new listing.

Patient Signature

My name typed into the answer section of the next question serves as my electronic signature
MM slash DD slash YYYY

Return to Telehealth Registration page

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