Date(Required) Name(Required)
First Name
Middle Name
Last Name
DOB(Required) Address(Required)
Gender Consent the call? Consent the text? Student Medicaid Are you a United States Military Veteran?(Required) Were you in Military Service?(Required) Do You Currently Have Stable Housing?(Required) If Homeless Can You Be Reached?(Required) If No, Are You Interested in Stable Housing Resources?(Required)
Emergency Contact Information
Substance Abuse/Addiction History Do You Use Recreational Drugs? Have You Ever Overdosed? Were You Administered NARCAN by Anyone? Do you Have you been enrolled in alcohol or other drug treatment in the last 90 days? Did you complete the program? Did you use other drugs?
Mental Health History Are You Currently Under a Psychiatrist’s Care?(Required) Are You Currently Being Prescribed Medication by a Psychiatrist?(Required)
Abuse History Have Your Ever Been Abused?(Required) If Yes, Check All That Apply(Required)
Primary Care History Do You Currently Have a Primary Care Physician?(Required) Are You Currently Being Prescribed Medications by Your Primary Care Physician?(Required) If Yes, List Your Prescribed Medications(Required)
If Yes, for Which Illness and or Issues Are You Currently Seeing Your Physician?(Required)
If No, Are You Interested in Obtaining a Primary Care Provider?(Required)
Current or Past Medical Conditions (Check all that apply and write F if the illness has a family history) Other Allergy Are You Pregnant?(Required) List Known Allergies(Required)
Tobacco Use History Do You Smoke?(Required)
Legal Occurrences Are You Currently Experiencing Any Legal Issues?(Required) If Yes Please Explain(Required)
Do You Have a Probation/parole Officer(Required) Are You Involved With Child Protective Services?(Required) Date(Required)
Consent for Treatment knowing that I am experiencing symptoms requiring The Health Experiences (THE)
services voluntarily consent to such medical care encompassing routing diagnostic procedures, alcohol and or drug assessment
mental health treatment and medical treatment by T.H.E medical staff.
RECEIVING MEDICAL SERVICES OTHER THAN OFFERED AT T.H.E: I understand that should major medical services become necessary, T.H.E will not be held medically legally financially responsible for providing such services. Should such services deemed medically appropriate by the consulting physician, The Health Experiences will make every reasonable effort to refer me to the proper clinic, hospital or doctor, Basic medical services will be provided by The Health Experiences Medical staff as determined by the consulting Physician.
RELEASE OF INFORMATION TO BE USED FOR PAYMENT, TREATMENT, OR FACILITY OPERATIONS: I authorize the release of medical record information including, but not limited to drug and/or alcohol related conditions, psychiatric conditions, and or HIV/AIDS related information to the responsible insurance carrier, third party payers, or their responsible representatives, review organizations or their representatives, the physician or agency staff responsible for method of care and/or any health care facility to which I am transferred from T.H.E All information released will be based on the minimum standard as defined by HIPPA.
FINANCIAL RESPONSIBILITY: I hereby authorize payment directly to The Health Experiences and/or the attending physician or their designees or all insurance benefits payable to me. I acknowledge that I am responsible for the payment for all services rendered by The Health Experiences
on my behalf.
PERSONAL BELONGINGS SEARCH: I understand that all personal belongings are subject to search by staff members in my presence. The purpose of this is to identify
articles that are not permitted in the building. I understand that legal items found during the course of the searches may be stored
and returned to me at the time of my discharge.
Date(Required) Date(Required) Date(Required) Date(Required)
AGAINST MEDICAL ADVICE DOCUMENT
This is to verify that I am leaving The Health Experiences against the advice of the attending physician and the agency administration. I acknowledge that I have been informed of the risks involved with my decision and hereby release the physician and The Health Experiences from all responsibility and any ill effects that may result from this action.
Date(Required) If patient is not available why
Telemedicine/Email/Text Consent 1. I understand that my health care provider wishes me to engage in a telemedicine consultation.
Consent(Required) I consent to The Health Experiences and its staff contacting me via text message and/or email for health promotions and appointment reminders. I also understand that standard text messaging may apply. I acknowledge that the responsibility of attending appointments and cancelling them still rests with me. I can opt out of the text and/ or email function at any time by submitting your wish to discontinue text or email services in writing. I agree to advise the practice of my mobile number and/or email changes if no longer in my possession.(Required)
By signing this form, I certify:(Required) Date(Required) Time Date(Required) Time
THE HEALTH EXPERIENCES
Date(Required) Time Date(Required) Time
Income Verification and Fee Agreement
Address
INCOME:
OTHER INCOME:
Medicaid will cover the fees for routine services I receive from The Health Experiences do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.
