CLICK TO CALL

New Patient Telehealth Enrollment (Under 18)

Please complete all sections of this form if your child is under age 18 and is not an established patient with SICHC. 

New Patient Telehealth Enrollment Form (Under 18)

Patient Name(Required)
MM slash DD slash YYYY
For access to health records 24 hours a day, 7 days a week.
Patient's Address(Required)
Ethnicity(Required)
Race(Required)
Language Spoken(Required)
Gender(Required)

Primary Insurance

Does the patient have Medical Insurance?(Required)
MM slash DD slash YYYY

Secondary Insurance

Does the Patient Have Secondary Insurance?(Required)
MM slash DD slash YYYY

Emergency Contact Information(Required)
First Name
Last Name
Relationship
Phone
 
Person to notify in the event of an emergency. | Note - Click on the plus "+" icon to the right to add a new Contact Person.
Contact Information of Parent(s)/Guardian(s)
First Name
Last Name
Relationship
Phone
 
Please list all parents and guardians of patient. | 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 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 submissions.

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

Parent / Guardian 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)

Patient's Medical History and Medications

Has the patient 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 the patient has 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 Hospitalization / Procedure.
Does the patient 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 Allergen | Allergens can be: Medication, Food, and/or Environmental

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

Signatures

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

© 2024 Southern Indiana Community Health Care.   PRIVACY

Social Media

FacebookYouTubeLinkedInEmail
TOP