Fillable New-Patient-Pedi-Packet-English TVFC Patient Eligibility Screening Record Form

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New-Patient-Pedi-Packet-English TVFC Patient Eligibility Screening Record Form

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Patient Registration Form
Patient Information
M.I.:
Mailing Address:
Apt #
Home Phone: Cell Phone: Work Phone:
If Voice, Please Select Preferred Number:
Sex:
q Male q Female
Social Security #:
Employer Name: Emergency Contact Name:
Emergency Contact Phone #: Relationship to Patient:
Phone:
Address of Person Responsible:
City/State/Zip: Relationship to Patient:
Email Address:
Race (please select):
Ethnicity (please select one):
o White
o American Indian or Alaska Native
o Asian o Hispanic or Latino
o Hispanic o Black or African American o Native Hawaiian or Pacific Islander o Not Hispanic or Latino
o Other o Decline o Decline
Preferred Language (please select one): o English o
Spanish
o Indian (including Hindi & Tamil)
o Sign Language o
Vietnamese
o
Mandarin/Cantonese
o
Other
Preferred Pharmacy Name & Location:
Ins. Co. Name Ins. Co. Name
Policy Holder Name: Policy Holder Name:
Policy Holder's Date of Birth: Policy Holder's Date of Birth:
Policy Holder's Social Security #: Policy Holder's Social Security #:
Patient Relationship to Policy Holder: Patient Relationship to Policy Holder:
X Date:
X Date:
Home Cell Work
Signature of Responsible Party:
First Name:
Patient Information
Additional Information and Responsible Party
I certify that I have read and agree to AccessHealth's payment policy. I am eligible for the insurance indicated on this form and I understand that payment is my responsibility regardless of
insurance coverage. I hereby assign to AccessHealth all money to which I am entitled for medical expenses related to the services performed from time to time by AccessHealth, but not to
exceed my indebtedness to AccessHealth. I authorize AccessHealth to release any medical information to my insurance carrier or third party payer to facilitate processing of my insurance claims.
I understand that failure to pay outstanding balances within 90 days of notification of the amount due will result in submission to an outside collection agency. I choose to receive
communications from AccessHealth by text or e-mail at the number or address stated above, including but not limited to communications about appointments, treatment, and payment. I
understand that such e-mails and texts may not be secure and there is a risk that they may be read by a third party.
MEDICARE BENEFICIARIES: I request that payment of authorized Medicare benefits be made to AccessHealth. I authorize any holder of medical information about me to release to CMS and its
agents any information needed to determine these benefits or the benefits payable for related services.
Previous Name (if applicable)
Date of Birth:
Responsible Party- If the patient is a minor (under the age of 18), the parent or guardian bringing the patient in will be listed as the guarantor.
Date of Birth:
Secondary Medical Insurance
Marital Status:
Family Physician or Pediatrician:
Additional Information (PLEASE FILL OUT ALL SECTIONS BELOW)
First Name:
City/State/Zip:
(Please Select Only One Option) Voice Text
Preferred Method of Contact for Reminder Calls and Other Electronically Generated Messages:
Rev.
8.2018
Primary Medical Insurance
Insurance Information
Printed Name of Responsible Party:
Last Name:
Social Security #:
Can we leave a message regarding your medical care & test results?
o Yes o No
Household Information
$
Total Monthly Household Gross Income:
Total People in Household:
Full-Time
Full-Time
Part-Time
Part-Time
Not in School
Not Employed
Housing Status: (Please indicate your living situation)
Both Parents
Father
Mother
Doubling Up
Not Homeless
Other
Spouse
Homeless Shelter
Street
Transitional
Unknown
Student:
Employment Status:
Agriculture Status:
Migrant Worker Seasonal Worker Not an Agriculture Worker
Do you think of yourself as:
Straight or heterosexual
Bisexual
Don’t Know
Lesbian, gay or homosexual
Something else, please describe
What is your current gender identity?(mark all that apply)
Male Female
Transgender male / Trans-man / Female-to-male
Transgender female / Trans-woman / Male-to-female
Genderqueer, neither exclusively male nor female
Decline to answer Additional gender category/ other (please specify):
EACH MEMBER OF YOUR HOUSEHOLD WHO WILL BE A PATIENT OF ACCESSHEALTH MUST COMPLETE THIS FORM.
Rev. 8/2018
Sexual Orientation / Gender Identity
Are you a US Military Veteran:
Yes
No
IMMUNIZATION REGISTRY (ImmTrac2)
Minor Consent Form
(Please print clearly)
Privacy Notication: With few exceptions, you have the right to request and be informed about information that the State
of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right
to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.texas.gov for more
information on Privacy Notication. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)
Questions? (800) 252-9152 • (512) 776-7284 • Fax: (866) 624-0180 • www.ImmTrac.com
Texas Department of State Health Services • ImmTrac Group – MC 1946 • P. O. Box 149347 • Austin, TX 78714-9347
PROVIDERS REGISTERED WITH ImmTrac2: Please enter client information in ImmTrac2 and afrm that consent
has been granted. DO NOT fax to ImmTrac2. Retain this form in your client’s record.
Stock No. C-7 Revised 09/2017
ImmTrac2, the Texas immunization registry, is a free service of the Texas Department of State Health Services (DSHS). The
immunization registry is a secure and condential service that consolidates and stores your child’s (younger than 18 years
of age) immunization records. With your consent, your child’s immunization information will be included in ImmTrac2.
Doctors, public health departments, schools, and other authorized professionals can access your child’s immunization history
to ensure that important vaccines are not missed.
The Texas Department of State Health Services encourages your
voluntary participation in the Texas immunization registry.
Consent for Registration of Child and Release of Immunization Records to Authorized Entities
I understand that, by granting the consent below, I am authorizing release of the child’s immunization information to DSHS
and I further understand that DSHS will include this information in the state’s central immunization registry (“ImmTrac2”).
Once in ImmTrac2, the child’s immunization information may by law be accessed by:
•
a public
health district or local health department, for public health purposes within their areas of jurisdiction;
• a physician, or other health-care provider legally authorized to administer vaccines, for treating the child as a patient;
• a state agency having legal custody of the child;
• a Texas school or child-care facility in which the child is enrolled;
• a payor, currently authorized by the Texas Department of Insurance to operate in Texas, regarding coverage for the child.
I understand that I may withdraw this consent to include information on my child in the ImmTrac2 Registry and my consent
to release information from the Registry at any time by written communication to the Texas Department of State Health
Services, ImmTrac Group – MC 1946, P. O. Box 149347, Austin, Texas 78714-9347.
By my signature below, I GRANT consent for registration. I wish to INCLUDE my child’s information in the
Texas immunization registry.
Parent, legal guardian, or managing conservator:
Printed Name
Signature
Date
*Children younger than 18 years old only.
Child’s Gender:
Male Female
Child’s Date of Birth
Child’s Address Apartment # Telephone
--
Child’s Last Name
City State Zip Code County
Mother’s First Name Mother’s Maiden Name
Child’s Middle NameChild’s First Name
Texas Department of State Health Services
Stock No. C-10
Immunization Unit Rev. 08/2016
Texas Vaccines for Children Program
Patient Eligibility Screening Record
A record of all children 18 years of age or younger who receive immunizations through the Texas Vaccines for Children (TVFC) Program must be kept in
the health care provider’s office for a minimum of five (5) years. The record may be completed by the parent, guardian, individual of record, or by the
health care provider. TVFC eligibility screening and documentation of eligibility status must take place with each immunization visit to ensure eligibility
status for the program. While verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccines
under the TVFC Program.
1. Child’s Name: ______________________________ _______________________________ ______
Last Name First Name MI
2. Child’s Date of Birth: ____ / ____ / ________
3.
Parent, Guardian, or Individual of Record:
______________________________ _______________________________ ______
Last Name First Name MI
4. Primary Provider’s Name: ______________________________ _______________________________ ______
Last Name First Name MI
5. To determine if a child (0 through 18 years of age) is eligible to receive federal vaccine through the TVFC Program, at each
im
munization encounter or visit, enter the date and mark the appropriate eligibility category. If Column A - F is marked, the child i
s
el
igible for the TVFC Program. If column G is marked the child is not eligible for federal VFC vaccine
.
Eligible for VFC Vaccine
State Eligible
Not Eligible
A
B
C
D
E
F
G
Date
Medicaid
Enrolled
No Health
Insurance
American Indian or
Alaskan Native
*Underinsured served by FQHC,
RHC, or deputized provider
** Other
underinsured
*** Enrolled
in CHIP
Has health insurance
that covers vaccines
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*Underinsured includes children with health insurance that does not include vaccines or only covers specific vaccine types. Children are only eligible for vaccines that
are not covered by insurance. In addition, to receive VFC vaccine, underinsured children must be vaccinated through a Federally Qualified Health Center (FQHC), a
Rural Health Clinic (RHC), or under an approved deputized provider. The deputized provider must have a written agreement with an FQHC or an RHC and the state,
local, or territorial immunization program in order to vaccinate underinsured children.
** Other underinsured are children that are underinsured but are not eligible to receive federal vaccine through the TVFC Program because the provider or facility is
not an FQHC or an RHC, or a deputized provider. However, these children may be served if vaccines are provided by the state program to cover these non-TVFC
eligible children.
*** Children enrolled in separate state Children’s Health Insurance Program (CHIP). These children are considered insured and are not eligible for vaccines through
the VFC Program. Each state provides specific guidance on how CHIP vaccine is purchased and administered through participating providers.
Texas Department of State Health Services Stock No. C-10
Immunization Unit Rev. 08/2016
Texas Vaccines for Children Program
Patient Eligibility Screening Record
(Continued)
Eligible for VFC Vaccine
State Eligible
Not Eligible
A
B
C
D
E
F
G
Date
Medicaid
Enrolled
No Health
Insurance
American Indian or
Alaskan Native
*Underinsured served by FQHC,
RHC, or deputized provider
**Other
underinsured
***Enrolled
in CHIP
Has health insurance
that covers vaccines
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Medicaid:
CHIP:
Medicaid Number:
_________________________________
CHIP Number:
________________________________________
Date of Eligibility:
_________________________________
Group Number:
________________________________________
Date of Eligibility:
________________________________________
Private Insurance:
Name of Insurer:
__________________________________
Insurer Contact Number:
______________________________
Policy or Subscriber
Insurance Name:
__________________________________
______________________________
Number:
Rev. 10/18
www.myaccesshealth.org
Welcome to Your Medical Home
MAKE EACH DOCTOR’S VISIT WORK FOR YOU!
Before your visit
o Write your own questions and worries. Do not worry if it’s a long list.
o If you see specialist, ask them to send their report to your primary provider here at AccessHealth.
o Confirm that your registration with AccessHealth is up to date.
On the day of your visit
o Provide us with your complete medical history and information from any another
medical provider.
o Put all your medicines in a bag and bring them with you to your doctor’s visit.
o Bring your Medicare, Medicaid, or other insurance card. Bring your list of questions.
o Please ask for help, ask a friend or family member to join you.
During your visit
o Relax! Ask questions! Take Notes. Tell us when you don’t understand. Remember we
want the very best for you.
o Ask us to tell you the values of your blood pressure, weight, and lab tests. Keep a record of these.
o Ask us when you should schedule your next visit.
After your visit
o Keep your medical information in one place-ready for the next visit.
Things that you can do for your self
o Learn as much as you can about how to care for your illness. The more that you know,
the better will be your health.
o Some health problems such as diabetes require you to change how you are eating and living. Talk
with your doctor, family and friends as to how you can make these changes. Start enjoying the
benefits of better health now.
o Make sure that you understand how to take your medicine. If you do not understand
how to take them, ask us for help.
o Don’t stop taking prescription medicine without first talking with your healthcare provider.
Call 24 Hours a Day, 7 Days a week
STAFFORD
281-342-4530
10435 Greenbough Dr, Ste 300
Stafford, TX 77477
MISSOURI CITY
281-342-4530
307 T
exas Parkway, Ste 100
Missouri City, TX 77489
RICHMOND
281-342-4530
400 Austin Street
Richmond,
TX 77469
BROOKSHIRE
281-822-4235
531 FM 359 S
Brookshire, TX 77423
EAST FORT BEND
281-342-4530
7707 Highway 6 South
Missouri City, TX 77459
When to Choose the Hospital/Emergency Room or AccessHealth, Your Medical Home
We are fortunate in our community to have access to 24-hour Emergency Room care. Of course, no one can time an
illness or injury to occur during the hours of a doctor’s office or clinic. But many acute illnesses, such as colds, flu, sprains,
strains, minor infections, minor cuts and bruises, skin rashes, common diarrhea, lower back pain, mild vaginal infections,
and irregular periods do not require an Emergency Room visit. Such ailments usually resolve on their own within a short
period of time. If they require medical treatment, they should always be addressed at AccessHealth, your Medical
Home. Generally, you should not go to the Emergency Room for medication refills, or medical problems that are chronic
in nature, unless you experience sudden worsening of your condition. Always choose your Medical Home for check-ups,
shots, and help with long term conditions.
So, when should one seek care at the Emergency Room? There are certain symptoms that should prompt an ER visit
even during operating hours of AccessHealth. These include:
1. Severe chest pain 7. Severe burns or inhalation of smoke
2. Vomiting Blood 8. Uncontrollable bleeding that will not stop
3. Sudden loss of consciousness or change in mental
status (acting strange)
9. Attempted suicide
10. Emergency labor/ childbirth
4. Sudden weakness of body parts 11. Severe trauma (injury)
5. Severe difficulty breathing 12. Sudden severe abdominal pain
6. Overdose of medicine or ingestion of toxic
substance. Call Poison Control at 1.800.222.1222
13. Sudden severe headache or sudden loss of vision
14. New seizure (convulsion)
Sometimes it may not be clear when an illness is serious enough to use the Emergency Room. Children and older
persons, or patients with underlying illness may need medical attention sooner than a young adult or otherwise healthy
person. If you are not sure what to do and it is during AccessHealth office hours, you should call or come into the office.
After hours you may call the office number and speak with the physician on-call about your illness.
It is important that you get proper care, and in a true emergency that means calling 911 or going to the Emergency
Room; otherwise it means care at AccessHealth, your Medical Home. If you go to the Emergency Room, please schedule
an appointment with AccessHealth within 10 days of your discharge.
Call 24 Hours A Day, 7 Days A Week
RICHMOND CENTER: 400 Austin St., Richmond, TX 77469
(281) 342-4530
ADULT CARE:
Monday – Friday: 7:00AM - 7:00PM; Saturday: 8:00AM - 12:00PM
PEDIATRIC CARE:
Monday, Tuesday, Thursday, Friday 7:00AM - 5:00PM; Wednesday: 7:30AM -
5:30PM; 2
nd
and 4
th
Saturday: 8:00AM - 12:00PM
STAFFORD CENTER: 10435 Greenbough Dr., Stafford, TX 77477
(281)261-0182
PEDIATRIC CARE: Monday – Friday: 7:00AM - 7:00PM; Saturday: 8:00AM - 12:00PM
DENTAL: Monday - Friday: 7:00AM - 7:00PM;
Saturday: 8:00AM – 12:00PM
MISSOURI CITY CENTER: 307 Texas Parkway, Missouri City, TX 77489
(281) 969-1800
ADULT CARE:
Monday, Tuesday & Thursday: 8:00AM - 5:00PM;
Wednesday: 9:00AM - 6:00PM; Friday: 7:00AM - 4:00PM
PEDIATRIC CARE:
Tuesday: 7:00AM – 7:00PM; Wednesday – Friday: 8:00AM – 5:00PM
EAST FORT BEND CENTER: 7707 Highway 6 South, Missouri City, TX 77459
(281) 342-4530
Monday – Friday: 8:00AM – 12:00PM
BROOKSHIRE CENTER: 533 FM 359 S., Brookshire, TX 77423 – (281) 822-4235
Monday – Thursday: 7:30AM – 5:30PM; Friday: 8:00AM – 5:00PM
Document#: COps.401.29.F1
Rev. 01/24/2019
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New-Patient-Pedi-Packet-English TVFC Patient Eligibility Screening Record Form

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Completed 2 July 2020

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