Fillable Family Health Center- 1600 Providence Drive, Waco, Texas

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Family Health Center- 1600 Providence Drive, Waco, Texas

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Page 1 of 3
What is your monthly household
income?
(Please select one)
I HAVE NO INCOME ($0)
MY MONTHLY INCOME IS:
_____________________________
MY YEARLY INCOME IS:
_____________________________
Do you have an Advanced
Directive or Living Will?
Gender Identity
MALE
FEMALE
TRANSGENDER MALE / FEMALE-TO-MALE
TRANSGENDER FEMALE / MALE-TO-FEMALE
OTHER
CHOSE NOT TO DISCLOSE
Sexual Orientation
STRAIGHT (NOT LESBIAN OR GAY)
LESBIAN
GAY
BISEXUAL
SOMETHING ELSE
DON’T KNOW
CHOSE NOT TO DISCLOSE
Preferred Pharmacy
FHC
OTHER________________
Marital Status
SINGLE
MARRIED
WIDOWED
DIVORCED
Preferred Language
ENGLISH
SPANISH
SIGNING / ASL
OTHER_________________
Ethnicity
(check one)
HISPANIC OR LATINO
NOT HISPANIC OR LATINO
Race
WHITE OR HISPANIC
BLACK OR AFRICAN
AMERICAN
ASIAN
AMERICAN INDIAN OR
ALASKA
NATIVE HAWAIIAN
OTHER PACIFIC ISLANDER
Veteran Status
ACTIVE DUTY
DISCHARGED (VETERAN)
NATIONAL GUARD
RESERVES
NONE
Farmer Worker Status
MIGRATORY FARM WORKER
NOT A FARM WORKER
SEASONAL FARM WORKER
In Public Housing
NO
YES
DOUBLED UP (LIVING WITH OTHERS)
IN A HOMELESS SHELTER
ON THE STREET
TRANSITIONAL HOUSING
PERMANENT SUPPORTIVE HOUSING
(through MHMR/Family Abuse Center)
How many people are
in your household?
(Include yourself)
__________________
Family Health Center- 1600 Providence Drive, Waco, Texas 76707
Please complete the following information and return to the receptionist.
PATIENT INFORMATION
PATIENT NAME
SEX AT BIRTH M F BIRTHDATE______/______/______ SSN_________/________/_________
PATIENT ADDRESS ________________________________________________________ APT # _________________________
CITY ___________________________________________ST ______________________________ZIP ______________________
HOME PHONE WORK PHONE CELL NUMBER
EMAIL ___________________________________________________________________________________________________
PREFERRED METHOD OF COMMUNICATION Telephone E-mail (MyChart) US mail
EMERGENCY CONTACT _____________________________RELATION TO PATIENT______________PHONE ______________
PATIENT EMPLOYER OCCUPATION __PHONE ______________
BILLING & INSURANCE INFORMATION
PERSON WITH FINANCIAL RESPONSIBILITY
NAME ________________________________________BIRTHDATE_______/________/_________SSN________/_______/_________
Relationship to patient_____________________________________________________________________________________________
MEDICARE PROVIDE COPY OF S.S. CARD MEDICAID GOOD HEALTH CARD COUNTY TITLE V OTHER
■
Page 2 of 3
General Consent to Treat and Acknowledgement of Teaching Services
SIGN THIS FORM AND GIVE TO RECEPTIONIST
I hereby consent to any and all treatment that my Family Health Center (hereinafter “FHC”) clinician
and I agree is necessary for me or for the patient(s) I am guardian for.
I understand and acknowledge that FHC is a teaching center, and my care, and/or the care of
patients(s) I am guardian for, at FHC may be provided by a clinician, including but not limited to
medical students and/or resident physicians and/or resident dentists, in a clinical training program. I
further understand and acknowledge that teaching services such as direct observation by other
physicians or medical students, case discussions, or photographic or video images of care activities
involving myself or my dependents are allowed for teaching purposes unless specifically denied by
me.
I further understand that as part of its health care services, FHC’s personnel and my clinician create
and maintain a record of care and services provided. I understand that such information may be
used and/or disclosed in the management and delivery of care and services provided by FHC, as
described in the Notice of Privacy Practices. I understand and acknowledge that FHC participates in
an electronic health record exchange program, and that if I seek treatment from other healthcare
facilities or providers participating in this exchange program, my health information, or that of the
patient(s) I am guardian for, may be shared between FHC and those other facilities or providers. I
understand and acknowledge that as part of receiving my healthcare at FHC, FHC’s clinicians and
other personnel may electronically request and/or provide health records for me and/or patient(s) I
am guardian for, to those participating facilities or providers. These records include, but are not
limited to prescription medication history, as well as information related to mental health treatment,
alcohol and/or drug abuse diagnosis, prognosis and treatment, and/or HIV (AIDS) testing/results
and/or treatment. I further understand that any such information from any source whatsoever may
become part of the requesting party’s health records on me and/or the patient(s) I am guardian for.
NOTICE OF PRIVACY PRACTICES
I hereby understand that I have the right to request a copy of the Family Health Center’s Notice of
Privacy Practices.
LIMITED ENGLISH PROFICIENCY
The Family Health Center proudly offers certain language assistance to its patients free of charge.
We also strive to make reasonable accommodations for its disabled patients.
PHOTOGRAPHY
I consent to the taking of photographic and/or video images for the purpose of identification and
documentation of my medical care.
STATEMENT OF FINANCIAL RESPONSIBILITY
I hereby understand I am the person primarily responsible for payment of all charges for services
rendered by FHC, regardless of any insurance coverage I might have, including Medicare or
Medicaid, and that such payment is due on demand. I further understand that in addition to such
service charges, I will be liable for any court costs, attorney’s fees, collection expense, or interest that
may be incurred should such actions be required to obtain payment for services rendered by FHC. I
certify that the patient and financial information given at the time of services rendered is accurate and
complete.
Page 3 of 3
ASSIGNMENT OF INSURANCE BENEFITS
In consideration of service rendered, I hereby irrevocably assign and transfer to FHC, all rights, title
and interest in benefits payable for services rendered by FHC. I hereby authorize and instruct the
insurance company (including but not limited to Medicaid, Medicare, County, Champus, and
commercial carriers), to pay directly to FHC all benefits due under the terms of my policy or policies.
I will pay FHC for all non-covered charges or for all legally allowed charges in excess of whatever
sums may be paid by the insurance company.
MEDICAID/MEDICARE ACKNOWLEDGMENT
I have been informed by a FHC healthcare provider that some services/items I request, including
those provided to me on __________________ (date), may not be covered under the Medicaid
and/or Medicare Programs as being reasonable and medically necessary for my care. I understand
that the Medicaid and/or Medicare Programs, or their health-insuring agent(s), determine the medical
necessity of services/items I request and receive. I also understand that I am responsible for
payment of services or items I request and receive if these services/items are determined by
Medicaid and/or Medicare not to be reasonable and medically necessary for my care.
OUTSIDE DIAGNOSTIC CHARGES
As of 6/1/95, laboratory testing for specimens/x-rays/ultrasounds obtained at FHC and sent to a
radiologist or independent lab will be billed to me directly from that independent facility (listed below).
There is also a lab handling fee for obtaining lab specimen(s) which is billed through FHC. Upon
receiving a statement, I understand that I am to contact that laboratory or radiology department to
arrange payment or exchange insurance information. I have been informed in writing and verbally of
this change. I understand that these diagnostic charges are now my responsibility.
INDEPENDENT DIAGNOSTICS: Baylor Scott and White - interpretation and procedure of lab or x-
rays/ultrasound; Radiology Consultants of Texas; Clinical Pathology Lab – lab tests not performed at
FHC; Central Texas Pathology – pap smears, tissue or surgical pathology. Certain other outside
diagnostic services as necessary may also be billed directly to the patient by service providers not
listed above.
PATIENT /GUARDIAN SIGNATURE
I have read and understand the aforementioned document.
PATIENT SIGNATURE ________________________________________________ DATE _______________________________
PARENT/GUARDIAN* SIGNATURE __________________________________________________________________________
RELATIONSHIP TO PATIENT ________________________________________________________________________________
WITNESS _________________________________________________________________________________________________
*Legal guardian must provide proof of guardianship, a copy of which must be attached to this form.
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Waco Family Health Center
PATIENT AND CENTER RIGHTS AND RESPONSIBILITIES
1
Approved by CPIC 6/8/16, reviewed and approved by CPIC 5/10/17, updated and approved
2/13/19
Name: __________________________ Date of Birth: ____/____/____ MR#: ____________
Welcome to the center.
Our goal is to provide quality health care to people in this community, regardless of their ability to pay.
As a patient, you have rights and responsibilities. The center also has rights and responsibilities. We
want you to understand these rights and responsibilities so you can help us provide better health care
for you. Please read and sign this statement and ask us questions you might have.
These rights and responsibilities address:
Human Rights
Payment for Services
Privacy
Health Care
Center Medical Home Responsibilities
Patient Responsibilities
Complaints
Termination
Appeals
I have read, understand, and accept the Waco Family Health Center Patient and Center Rights and
Responsibilities. A copy of this policy is available to me upon my request.
Signature: ____/_____/____
Name: Date
[Print Name]
If signing for a minor, ____________________________
[Print Minor’s Name]
Waco Family Health Center
PATIENT AND CENTER RIGHTS AND RESPONSIBILITIES
2
Approved by CPIC 6/8/16, reviewed and approved by CPIC 5/10/17, updated and approved
2/13/19
A. Human Rights
You have a right to be treated with respect regardless of race, color, marital status, religion, sex, gender,
gender identity, sexual orientation, national origin, ancestry, physical or mental handicap or disability,
age or other grounds as applicable to federal, state and local laws or regulations.
B. Payment For Services
1. You are responsible for giving staff accurate information about your present financial status
and any changes in your financial status. The staffs need this information to decide how
much to charge you and/or so they can bill private insurance, Medicaid, Medicare, or other
benefits for which you may be eligible. If your income is less than the federal poverty
guidelines, we will help determine your eligibility to receive a discounted fee schedule.
2. You have a right to receive explanations of the center’s bill. You must pay, or arrange to pay,
all agreed fees for medical services, with the exception of dental services, which are
provided on a prepaid basis. For any unpaid balance you may have, please contact our
billing department for a payment plan.
3. Federal law prohibits the center from denying you primary health care services which are
medically necessary solely because you cannot pay for these services. The Family Health
Center may require a Co-Pay or a Nominal Fee from our patients. If you cannot afford this
required payment, we would be happy to assist you to determine potential eligibility for
programs that may reduce your required fee.
C. Privacy
You have a right to have your interviews, examinations and treatment in privacy. Your medical records
are also private. Only legally authorized persons may see your medical records unless you request in
writing for us to show them to, or copy them for, someone else. In certain instances, the center may be
required to report to the Texas Department of State Health Services regarding your health condition or
illness status. The Privacy and Confidentiality in Delivery of Services Policy sets forth the ways in which
your medical records may be used or disclosed by the center and the rights granted to you under the
Health Insurance Portability and Accountability Act (“HIPAA”). This document is available to you upon
request.
D. Health Care
1. You are responsible for providing the center with complete and current information about
your health or illness, so that we can give you proper health care. You have a right, and are
encouraged, to participate in decisions about your treatment.
2. You have a right to information and explanations in the language you normally speak and in
words that you understand. You have a right to information about your health or illness,
treatment plan, including the nature of your treatment; its expected benefits; its inherent
Waco Family Health Center
PATIENT AND CENTER RIGHTS AND RESPONSIBILITIES
3
Approved by CPIC 6/8/16, reviewed and approved by CPIC 5/10/17, updated and approved
2/13/19
risks and hazards (and the consequences of refusing treatment); the reasonable
alternatives, if any (and their risks and benefits); and the expected outcome, if known. This
information is called obtaining your informed consent.
3. You have the right to receive information regarding “Advance Directives.” If you do not
wish to receive this information, or if it is not medically advisable to share that information
with you, we will provide it to your legally authorized representative.
4. You are responsible for appropriate use of center services, which includes following staff
instructions, making and keeping scheduled appointments, and requesting a “walk in”
appointment only when you are ill. Center professionals may not be able to see you unless
you have an appointment. If you are unable to follow instructions from the staff, please tell
them so they can help you.
5. If you are an adult, you have a right to refuse treatment or procedures to the extent
permitted by applicable laws and regulations. In this regard, you have the right to be
informed of the risks, hazards, and consequences of your refusing such treatment or
procedures. Your receipt of this information is necessary so that your refusal will be
“informed.” You are responsible for the consequences and outcome of refusing
recommended treatment or procedures. If you refuse treatment or procedures that your
healthcare providers believe is in your best interest, you may be asked to sign a Refusal to
Permit Medical Treatment or Services / Against Medical Advice Release Form.
6. You have a right to health care and treatment that is reasonable for your condition and
within our capability, however, the center is not an emergency care facility. You have a right
to be transferred or referred to another facility for services that the center cannot provide.
The center does not pay for services that you receive from another healthcare provider or
any required transportation service.
E. Family Health Center Medical Home Responsibilities
1. The practice is responsible for coordinating your care across different settings.
2. The care team will provide you access to evidence-based care, patient/family education and
self-management goals.
3. The front office staff at your clinic will help transfer your medical records. You will be
required to sign a release of information form.
4. You will receive a written clinical summary at each visit.
F. Patient Responsibilities
1. You have a right to receive information on how to use the center’s services appropriately.
You are responsible for using the center’s services in an appropriate manner. If you have
any questions, please ask us.
Waco Family Health Center
PATIENT AND CENTER RIGHTS AND RESPONSIBILITIES
4
Approved by CPIC 6/8/16, reviewed and approved by CPIC 5/10/17, updated and approved
2/13/19
2. You are responsible for the supervision of children you bring with you to the center. You are
responsible for your children’s safety and the protection of other patients and our property.
3. You have a responsibility to keep your scheduled appointments. Missed scheduled
appointments cause delay in treating other patients. If you do not keep scheduled
appointments you may be subject to disciplinary action pursuant to the center’s policies and
procedures.
G. Complaints
1. If you are not satisfied with our services, please tell us. We want suggestions so we can
improve our services. Staff will tell you how to file a complaint. If you are not satisfied with
how the staff handles your complaint, you may file a complaint in writing to the center’s
Board of Directors.
2. If you make a complaint, no center representative will punish, discriminate or retaliate
against you for filing a complaint, and the center will continue to provide you services.
H. Termination
If the center decides that we must stop treating you as a patient, you have a right to advance written
notice that explains the reason for the decision, and you will be given thirty (30) days to find other
health care services. However, the center can decide to stop treating you immediately if you have
created a threat to the safety of the staff and/or other patients. You have a right to receive a copy of
the center’s Patient Dismissal Policy.
Reasons for which we may stop seeing you include:
1. Failure to obey center rules and policies;
2. Intentional failure to accurately report your financial status;
3. Intentional failure to report accurate information concerning your health or illness;
4. Intentional deception of care team regarding medications and obtaining care
outside FHC;
5. Verbal abuse of or inappropriate behavior toward our staff or creating a significant
disturbance and/or
6. Creating a threat to the safety of the staff and/or other patients.
I. Appeals
If the center has given you notice of termination of the patient and center relationship, you have the
right to appeal the decision to the grievance committee in writing. Unless you have a medical
emergency, we will not continue to see you as a patient while you are appealing the decision.
Extended Hours Clinic Operations
Extended Hours services will be located at the following address:
Family Health Center (OPC Clinic)
1600 Providence Drive
Waco, TX 76707
Purpose: To provide access for routine and urgent care to established FHC patients, outside
of regular business hours. Patients presenting as walk-ins after 4:15 PM to any Family Health
Center Clinic who cannot be reasonable accommodated may be scheduled in extended
hours.
Hours of Operation:
Monday-Thursday: 5:00PM - 8:00PM
Saturday: 8:30AM – Noon
*Hours may be modified or cancelled based on staff availability, holidays or inclement
weather.
Services provided: (For established FHC patients)
•
Urgent care
•
Wellness visits
•
Routine care
•
Nurse visits
Services not provided during Extended Hours Include:
•
Prenatal care
•
Fractures
•
Hospital follow-ups
•
Emergency care
•
Radiology (X-ray)
•
FHC Pharmacy
•
Other services may be limited depending upon available provider’s scope of practice
❖
Please call your assigned clinic between 8am − 5pm in order to schedule or
come directly to Extended Hours Clinic as a Walk-in patient between 5pm −
8pm.
❖
Patients presenting to extended hours will be seen on a first come, first serve
basis as clinic flow allows.
Diabetes - Type I o Type II? __________
High Blood Pressure
High Cholesterol
Heart Failure / CHF
Heart Attack/Coronary Artery Disease
Pacemaker/Defibrillator
Stroke
Kidney Disease
Asthma
COPD/Emphysema/Chronic Brocnchitis
Cancer - What type?______________
Thyroid Problems
Peripheral Vascular Disease/Circulation problems
Bloot Clot/DVT
Bleeding disorder
Anemia
Tuberculosis
Other________________________
When was your last PAP smear?
Ever had an abnormal PAP?
if so, when?___________
FIRST day of your last menstrual period?
When was your last mammogram?
Ever had an abnormal mammogram?
If so, when?______________
Are you currently pregnant? Due date: ___________
Ever had complications with your pregnancy?
___________________________________________
Patient Name: _______________________
Today’s Date:
_________________
Age: __________________
Date of birth: _______________________
MRN (Office use only):
_______________________
Reason for today’s visit:_______________________
Physician’s Address:
_______________________________
Name of last primary care physician: ___________________
Date last seen:
_______________________
Total Pregnancies
Live Births
Premature Births
Miscarriages
Abortions
C-Sections
Vaginal Birth after C-Section
Medical History - Check the Conditions YOU have ever had
Women ONLY
List medications you are ALLERGIC to
List current Medications & Doses you are
taking (Ex: Prinivil 40 mg daily)
Hepatitis - What type? _______
Cirrosis/Liver Disease
Alcoholism/Drug Addiction
Arthritis - What type? __________
Gout
Osteoporosis/Thin bones
Prostate Problem
HIV/AIDS
Herpes
Other STD/Venereal Disease
Depression
Anxiety
Suicide Attempt
Other Mental Illness
Seizure
Paralysis
Migraines
Other: _______________________
NAME
DOSE
___________________________
____________
___________________________
____________
___________________________
____________
___________________________
____________
___________________________
____________
___________________________
____________
NAME
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
How many?
Previous Surgeries
Date
Type of Surgery
Gallbladder
Appendix
Tonsils
Hernias
Hysterectomy - ovaries removed?
Tubal Ligation (tubes tied)
Breast Biopsy
Back Surgery
Other: ____________________________
Other: ____________________________
Health Habits
How much of each do you use per day?
(if not everyday, how much per week?)
Caffeine
_______________________
____
Alcohol
_______________________
____
Tobacco
_______________________
____
Street Drugs
_______________________
____
Any exposure to hazardous materials?
___________________________________
Travel to a foreign countries?
___________________________________
_
Occupation/Travel
FAMILY HISTORY: List family members with the following conditions (NOT YOURSELF)
Diabetes
_________________________________________________
High Blood Pressure
_________________________________________________
High Cholesterol
_________________________________________________
Heart Attacks
_________________________________________________
Kidney Disease
_________________________________________________
Bleeding problem
_________________________________________________
Strokes
_________________________________________________
Cancer (what kind?)
_________________________________________________
Arthritis
_________________________________________________
Asthma
_________________________________________________
COPD/Lung Problems _________________________________________________
Are your parents still living?
No, what was the age and cause of death?_________________________________________________
Are your siblings still living?
No, what was the age and cause of death? _________________________________________________
__________________________________________________________________________________________
Symptoms: Please check if you are experiencing any of the following
Unintentional weight loss
Diarrhea or Vomiting
Blood in stools or urine
Leaking urine or stool
Night sweats/Fevers
Penile or Vaginal discharge
Shortness of breath
Swelling in fee/ankles
Irregular/Painful periods
Chest pain
Rash
Erection problems
Vision problems
Too thirsty
Constipation
Persistent cough
Suspicious lumps or bumps (where?)__________
Difficulty breathing when lying down
Fainting
Forgetfulness
New headache
Trouble sleeping
Pain - where? __________
Other:________________
MEDICATION LIST
Dear Patient,
List all of the medications that you are currently taking. Please include: drops,
inhalers, contraceptives, patches that contain medication, over- the counter
medication, dietary and herbal supplements.
Name: ___________________________________________
Date of Birth: _____________________________________
Name of medication
(s)
Dose strength:
(milligrams, units,
drops, etc.)
How many times a day
do you take this
medication?
AUTHORIZATION FOR USE AND DISCLOSURE OF
PROTECTED HEALTH INFORMATION
Family Health Center ◦ 1600 Providence Dr ◦ Waco, TX 76707
Patient Name: __________________________________________ Date of Birth: ________________________ SS #: ________________________________
Address: _____________________________________ Apt # _______ City: ____________________________ State: ________ Zip Code:
Obtain Information From: Release Information To:
Name: ________________________________________________________ Name: ____________________________________________________________
Address: ______________________________________________________ Address: ___________________________________________________________
City: ______________________ State: _________ Zip Code_________ City: __________________________ State: _________ Zip Code__________
Ph #: ___________________________ Fax #: _______________________ Ph #: ____________________________ Fax #: __________________________
PATIENT INFORMATION IS NEEDED FOR THE FOLLOWING:
O Transfer Care O Treatment O Insurance O SS Disability
O Legal Purposes O School/Daycare O Personal Use O Other, please specify ____________________________________
Dates of Treatment: __________________________________________________________________________________________________________________
Information to Be Used and/or Disclosed:
O Face Sheet O History and Physical O Office Notes O Lab/Pathology Reports O Operative Reports
O Consultation Reports O X-ray Reports Other (Specify) _______________________________________________________________________
Substance Abuse, Mental Health, HIV/AIDS
I understand that my medical or billing records might contain information in reference to drug, alcohol, psychiatric care, sexually
transmitted disease, Hepatitis B or C testing, HIV/Aids (Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome),
and/or other sensitive information and I agree to this release.
Time Limit & Right to Revoke Authorization
Except to the extent that action has already been taken in reliance on this authorization, at any time I can revoke this authorization
by submitting a notice in writing to the facility Privacy Office at 1600 Providence Dr, Waco, TX 76707. Unless revoked, this
authorization will expire on the following date or event: or one year after the date of the signing of
this authorization as shown below.
Re-Disclosure
I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and will no longer be
protected by the Health Insurance Portability and Accountability Act of 1996. The facility, its employees, officers, and physicians are
hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized
herein.
Signature of Patient or Personal Representative Who May Request Disclosure:
I understand that Family Health Center may not condition my treatment on whether I sign this authorization form unless specified
above under Purpose of Request. I can inspect or copy the protected health information to be used or disclosed. I authorize Family
Health Center to use and disclose the protected health information described above.
Signature: ________________________________________________________________ Date: ______________________________________________
Patient or Legally Authorized Representative
___________________________________________________________________ _____________________________________________________
Printed Name of Patient or Legally Authorized Representative Relationship to Patient
Fees/Charges will comply with all laws and regulations applicable to release of Protected Health Information. Payment is due at the time of release.
Authorization to Access Information
I _____________________________________,
(printed adult patient
name
hereby authorize
Family Health Center staff to disclose
information
to the following individual(s)
For
_________________________________,
(printed minor patient
name
I hereby authorize Family Health Center staff to disclose
health information
to the following individual(s)
________
___________________________
(name)
___________________________________
(name)
___________________________________
(name)
___________________________________
Patient/Parent Signature
For Clinic Use Only:
A
ppropriate identification
has been presented and verified
Name of staff member/department:
Clinic Name:
______________________
Authorization to Access Information
I _____________________________________,
name
& date of birth)
Family Health Center staff to disclose
any and all of
to the following individual(s)
until further notice is given.
OR
_________________________________,
name
& date of birth)
I hereby authorize Family Health Center staff to disclose
any and all of
to the following individual(s)
until further notice is given.
___________________________
________________________
(relationship)
___________________________________
________________________
(relationship)
___________________________________
________________________
(
relationship)
___________________________________
________________________
Date
Approved CPIC 4/10/13
, 3/9/16
has been presented and verified
.
Name of staff member/department:
__________________________________________
______________________
Date:______________
Authorization to Access Information
any and all of
my health
until further notice is given.
any and all of
my child’s
until further notice is given.
________________________
(relationship)
________________________
(relationship)
________________________
relationship)
________________________
, 3/9/16
, 3/8/17
__________________________________________
MyChart is a personalized and secure online access to your medical
record. It enables you to securely manage and receive information about
your health.
With MyChart, you can:
•
Request and/or schedule medical appointments
•
View your health summary
•
View test results
•
Communicate securely with your medical care team.
Activate your MyChart Today!
MyChart is a FREE service offered to our patients.
Please complete form and give to your nurse to start!
User Name: _______________________________________________
Temporary Password: _____
FHC123_____________________________
Security Question: What was your high school mascot?______________________
Or
What is your Favorite Animal?____________________________________
Email: ________________________________________________________
Once your account is active, you will have access to change your password.
!
Manage your care, anywhere, anytime.
App Available!
Financial Assistance
Heart of Texas Community Health Center (HOTCHC) (dba Family Health Center) offers financial screening services to all patients. Screening for
financial assistance through the HOTCHC Eligibility Department is offered for various financial assistance programs (see information below).
Medical Insurance Plans Accepted at Heart of Texas Community Health Center
Heart of Texas Community Health Center (dba Family Health Center) accepts many Third Party
Plans as well as various State Programs (i.e., Medicaid, Healthy Texas Women’s Program, Family
Planning Grant, Title V, etc.).
The following is a partial list of third party plans that the Family Health Center accepts;
however, to ensure that you receive the maximum benefits from your plan, please contact your
specific plan to verify if we are a participating (in-network) provider as this is not an all-
inclusive list.
Amerigroup – Medicaid (Star plan)
BlueCross BlueShield – Commercial PPO/HMO and Medicare Advantage (MA)
ChampVA - Civilian Health and Medical Program of the Department of Veterans Affairs
CIGNA – Open Access and Choice Fund PPO
FirstCare – Commercial PPO/HMO
Humana – Commercial PPO/HMO and Medicare Advantage (MA)
Molina – CHIP Kids and CHIP Perinate
Superior – Medicaid, CHIP Kids and CHIP Perinate
Scott & White Health Plans – Commercial PPO/HMO, Medicare Advantage (MA) and Medicaid
(Rightcare)
Tricare - Health insurance plan for military members, their families, and retirees
Tricare for Life – Health insurance plan for military members who have Tricare and Medicare
Part A or Part B
UnitedHealthCare – Commercial PPO/HMO, Medicare Advantage (MA), Medicaid StarPlus and
Star Kids
We look forward to serving your healthcare needs. If you have questions about fees, want to
make a payment plan, or have questions about possible financial assistance, please contact our
Billing Department at 254-313-4200.
Payment Options and Return Check Policies
Payment Options
Heart of Texas Community Health Center (dba Family Health Center) offers a
variety of payment options for patients to help them meet their financial
responsibilities, such as Prompt Payment Options and payment plans.
Prompt Payment Option – patients may elect to receive a 50% discount on a self-
pay balance when, 1) the balance due is not a cost-share or co-insurance balance
due by the patient after insurance paid, or 2) when the patient elects not to use
their insurance benefits and is considered as self-pay (full pay) for the specified
services.
When electing the prompt pay option, the patient is expected to pay the
remaining balance owed after the discount is applied either prior to the services
being rendered, or within 30 days of the request. NO personal checks are
accepted for prompt pay payments.
Payment Plan Option – patients may elect to set up a monthly payment plan that
allows them to pay out their balances over time.
Patients should contact the Billing Department at 1600 Providence Drive, Waco,
TX 76707, phone# 254-313-4200 for assistance with payment options.
Return Check Policy
Personal Checks that get returned as “Insufficient Funds” or as a “Stopped
Payment” will incur a $30 service charge. The amount of the check and service
charge will be required to be paid by a different payment source (no personal
check) within 10 business days of the returned check notice from the bank.
Patients will need to come to the Billing Department to make their payment. If
the payment due is not made within the 10 business days, the check will be
turned over for further action at the District Attorney’s office.
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Family Health Center- 1600 Providence Drive, Waco, Texas

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Completed 13 March 2021

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