RSN Clone of KCHC Patient Registration Form

Patient Registration Form

Terms and Conditions
Welcome to Online Patient Registration!

Please read and accept the Terms and Conditions below to begin your registration.

All information entered in this form is protected and secure.

Please complete all required questions.

Please note, we do not receive your registration until all required questions are completed and you select the Submit My Registration to KCHC.
Terms and Conditions

By entering information in this online form you agree that you are completing a patient registration with Kinston Community Health Center, Inc. for yourself, your minor child, dependent, or person for which you have legal guardianship.

You understand this information will be used for patient registration, treatment, and payment activities at Kinston Community Health Center, Inc.

You understand that this is a HIPAA compliant online form.

You understand it is your responsibility to protect your protected health information by having the appropriate security software on your electronic device and closing your browser at the conclusion of this registration.

Patient Registration Form
Today

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Age
Social Security Number*
Days
Home Address (Physical Address Where You Live)*

Street Address

Street Address Line 2

CityState

Zip Code
Is your Home Address the same as your Mailing Address?

Yes
Mailing Address (Address Where You Receive Mail)

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*

Area CodePhone Number
Ok to leave a message*
Home Phone Number

Area CodePhone Number
Ok to leave a message
Work Phone Number

Area CodePhone Number
Ok to leave a message
I would like to receive text
Email
example@example.com
I would like to receive emails
Patients in our practice may be contacted via phone, email, or text message for appointment reminders, to obtain feedback on your experience with our healthcare team, and to provide general health reminders/information. What is your communication preference?*

Text my cell phoneCall my cell phoneCall my home phoneEmail meI do not have a phone or email
COMMUNICATION CONSENT: By signing below, you consent to receive communications via your preferred communication method specified above, as well as any number or email to which you have established automatic forwarding. *

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Patient/Legal Guardian Signature
Patient/Legal Guardian Signature

MonthDayYear
DateHourMinutesAM/PM Option

Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Relationship To Patient*
Emergency Contact Phone Number*

Area CodePhone Number
Medical/Dental Plan Information - Medicaid/Medicare
Uninsured Patient

The patient is uninsured. Patient does not have Medicaid, Medicare, or medical/dental insurance.
Is the patient a Medicaid recipient?*
Enter the Medicaid ID number for the patient.

Medicaid Identification Number

Medicaid
Does the patient have Medicare? Answer "yes" for original Medicare and Medicare Advantage plans.*
Enter the Medicare number for the patient.

Medicare Beneficiary Identification Number

Medicare

	Medicaid Identification Number
Medicaid

	Medicare Beneficiary Identification Number
Medicare

Medical/Dental Plan Information - Commercial/Private Insurance
Does the patient have a commercial insurance plan? This includes plans like BlueCross Blue Shield (BCBS), insurance from work, and Medicare supplemental plans.

Take Photo of Insurance Card(s) Please take photos off all Medicaid, Medicare, commercial, and/or dental plan card(s) listed for the patient. If you are unable to take a photo, please bring all cards to your first appointment.

Parent/Guardian Information
Parent/Guardian

Same as patient
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Social Security Number
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number

Patient Defined Information
Race*
Ethnicity*
Sexual Orientation*
Current Gender*
Gender Identity*
Preferred Pronoun*
Sex at Birth*
Other Sexual Orientation
Other Gender Identity
Marital Status*
Preferred Language*
Do you need transportation assistance?*
What is the highest grade completed?*
Student Status
Do you need an interpreter?*
Are you registered to vote?
Employer Information
is the patient employed?*
Employer Name*
Employer Phone Number

Area CodePhone Number
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pharmacy Information
Pharmacy Name*
Pharmacy Phone Number

Area CodePhone Number
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Care Needs - Dental
DENTAL CARE (Select all that apply to the patient.)*

I do not need dental services as this time.Establish Dental Care - I need a regular dentist to provide cleanings and dental care.Emergency Dental Care - I have a tooth pain, swelling, and/or a damaged tooth.Dentures - I am interested in getting dentures.Other
Have you received dental care (including dental x-rays) at a dental practice in the last five (5) years?*

YesNo
Name of Dental Practice*
Dentist Name

First NameLast Name
Dental Practice Address

Street Address

Street Address Line 2

CityState

Zip Code

Authorization To Release Medical Information
In accordance with Federal government privacy rules implemented through the Healthcare Portability Act of 1996 (HIPAA), in order for your healthcare provider or staff of Kinston Community Health Center, Inc. to discuss your condition with members of our family or other individuals that you designate, we must obtain your authorization prior to doing so. In the event of an emergency or if you are unable to give your authorization due to the severity of your medical condition, the law stipulates that these rules may be waived.

This authorization may be used to permit a covered entity (as such term is defined by HIPAA and applicable North Carolina law) to use or disclose an individual’s protected health information. Individuals completing this form should read the form in its entirety before signing and complete all the sections that apply to their decisions relating to the use or disclosure of their protected health information.
Authorization to Release Medical Information*

No Authorization - I do not want my protected health information released to anyone other than myself. I do not authorize Kinston Community Health Center to release information concerning my medical care to any individual except as set forth above.Authorization - I authorize Kinston Community Health Center, Inc. to release any or all information concerning my medical care to the following individuals listed below. I must revoke this authorization in writing.
I hereby authorize the designated parties below to request and receive the release of my protected health information regarding treatment, payment or administrative operations. I understand the identity of designated parties must be verified before the release of any information.

I hereby authorize the release of PHI as follows (choose one):*

I authorize the release of my complete record (including records relating to mental healthcare, communicable disease, HIV or AIDS, and treatment of alcohol or drug abuse orI authorize the release of my complete health record with the exception of the following information: Mental Health Records, Communicable diseases (including HIV and AIDS), and Alcohol/drug treatment.
I understand that I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent Kinston Community Health Center may decline to provide treatment to me.
Authorization to Mail, Call, Email or Text:

I certify that I understand the privacy risks of the mail, phone call, email, or text. I hereby authorize Kinston Community Health Center to mail, call, email, or text me with communication regarding my healthcare, including but not limited to such things as appointment reminders, referral arrangements, and laboratory results. I understand That I have the right to revoke this authorization at any time by notifying Kinston Community Health Center to that effect in writing.

Authorization To Release Medical Information continued
I understand that I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent Kinston Community Health Center may decline to provide treatment to me.
Assignment of Insurance Benefits:

I hereby authorize direct payment of my insurance benefits to Kinston Community Health Center for services rendered to my dependents or me by the physician/ practitioner. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any co-pay or balance due that Kinston Community Health Center is unable to collect from the insurance carrier for whatever reason.
Authorization to Release Non-Public Personal Information:

I certify that I have received and read a copy of Kinston Community Health Center Notice of Privacy Practices of the date on the signature below. I hereby authorize Kinston Community Health Center to release any of my dependents medical or incidental non-public protected health information as described in the privacy practices that may be necessary for medical evaluation, treatment and treatment, consultation or the processing of insurance benefits. I understand that I retain the rights granted to me through Kinston Community Health Center Privacy Practice. I hereby consent to Kinston Community Health Privacy Practice.
Consent to Treatment

I hereby consent to evaluation, testing, and treatment as directed by Kinston Community Health Center physician and practitioner.
Signature*

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Patient/Legal Guardian Signature
Signature Date

MonthDayYear
DateHourMinutesAM/PM Option

Sliding Fee Discount Program
Kinston Community Health Center, Inc. is not a free clinic.

Kinston Community Health Center, Inc. provides treatment to all persons regardless of their ability to pay.

Ability to pay is not the same as not wanting to pay for treatment.

Ability to pay is defined by your family size and income.

We offer discounts on the charges for treatment services to all patients including insured patients.

To get these discounts, you must apply for our Sliding Fee Discount Program.

When you apply, we will ask for proof of your income and you will need to tell us you family size.

If you do not apply today, you may apply at any time in the future.
Would you like to apply for the Sliding Fee Discount Program today?*
I have declined to apply for the Sliding Fee Discount Program. I understand that declining today does not revoke my right to apply for the Sliding Fee Discount Program whenever I choose to do so and I may apply at any time in the future.

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Parent/Legal Guardian Signature
Signature Date

MonthDayYear
DateHourMinutesAM/PM Option

Sliding Fee Discount Program Application
Kinston Community Health Center, Inc. (KCHC) provides access to services without regard for a person's ability to pay; the ability to pay is determined by a patient's annual income and family size according to the most recent U.S. Department of Health & Human Services Federal Poverty Guidelines.

Eligibility

All KCHC patients are eligible to apply for the Sliding Fee Discount Program. Determination of the discount, if any, is dependent upon household income and household size in comparison to the current Federal Poverty Guidelines. This discount may apply to insurance / Medicare copays and Medicaid Family Planning non-covered services.

Eligibility Period

Information must be updated every twelve (12) months or any time you experience a change household income or household size. It is your responsibility to notify KCHC of changes in your household size and/or income. We will contact you to reverify every twelve (12) months.
Family and Income Information*
The information that I have provided in this application is true and correct. I understand that Kinston Community Health Center will ensure this information will be protected as private and confidential. I understand this information will be shared with the US DHHS Health Resources and Services Administration (HRSA) for reporting purposes. I understand that I am responsible for reporting changes in my family size and/or income to Kinston Community Health Center, Inc.*

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Patient/Legal Guardian Signature
Signature Date

MonthDayYear
DateHourMinutesAM/PM Option

Patient Financial Policy
Kinston Community Health Center provides dental, medical, and behavioral health services to insured and uninsured patients. Kinston Community Health Center is not a free clinic. A medical practice, like any business, depends on timely payments. We want you to know your financial responsibility for our services. This agreement gives you information about your financial responsibility for services at Kinston Community Health Center.

Account Guarantor

Your account guarantor is the person financially responsible for paying charges on your account. Often, you are your own guarantor. A minor child’s guarantor can be a person with legal guardianship of the minor.

We will ask you to give us account guarantor information during registration. You can make updates and changes by visiting one of our Patient Access Representatives.

When Payment Is Due

Co-pays or nominal charges (for those eligible for our Sliding Fee Discount Program) are due at check-in. We mail billing statements to you during the first week of each month for balances on your account that were unpaid at the end of the prior month. Payment is due when you receive a billing statement from Kinston Community Health Center.

Insurance Coverage

Let us know if you have insurance when your register. If you get insurance after registration, tell us at your next appointment.

Bring your insurance card to each appointment. Let us know when there are changes to your insurance.

Sliding Fee Discount Program

We offer a Sliding Fee Discount Program for eligible patients. All patients may apply regardless of whether you do or do not have insurance.
- We use your family size and income for eligibility decisions.
- Patients with family size and income below 200% of the federal poverty guidelines will be eligible for Sliding Fee Plan Discounts.
- Patients with family size and income at or below 100% of the federal poverty guideline) will pay a nominal charge. The Board of Directors of Kinston Community Health Center set nominal charge amounts.
- Sliding fee discounts apply after all insurance payments have processed.
- The amount on your bill, after your approval for the Sliding Fee Discount Program, is your responsibility. This is the amount you are “able to pay”. We cannot waive the amount you are able to pay.
- The Sliding Fee Discount Program is the last payer after all benefit plans. You must apply for all public and private insurance that you qualify for including North Carolina Medicaid, North Carolina HealthChoice, Medicare, and employer insurance plans.
Financial Counseling

We have a Financial Counselor on-site from 8am – 5pm to help you with payment arrangements if needed. Call our Financial Counselor at (252) 522-9800 ext. 6280.

Patient Financial Policy continued
Patient Refunds

If you pay more than your account balance, you may have an account credit. If you ask for a refund for an account credit, we will issue a refund to the guarantor on your account. Please allow up to 30 days for processing.

Past Due and Delinquent Account Balances

Kinston Community Health Center places delinquent accounts with collection agencies. The monthly billing statement we mail you will tell you the status of your account. We will also contact you before we place your account with a collection agency. Call our Financial Counselor at (252) 522-9800 to set up a payment plan.

Appointment Scheduling

We schedule an appointment for you based on the date, time, and provider you ask for and the reason for the visit. When you schedule an appointment, please follow our practice rules:
- Tell us how you want us to contact you to confirm your appointment. We will send appointment confirmation messages to you by phone, text, or email.
- We have the right to reschedule appointments because of refusal to pay co-pays or nominal charges at check-in.
- Check in at our front desk by the arrival time in your appointment confirmation message.
- Bring your medication and forms with you.
- If you need to cancel your appointment, call us at 252-522-9800 at least 24 hours before your appointment.
- If you have an excessive no show history a warning letter will be sent, defined as follows:
o Two (2) or more no show visits within the past six (6) months for all routine and sick medical and dental appointments.

o One (1) or more no show visits for major and/or surgical dental visits within the past six (6) months.

o One (1) or more no show visits for medical procedure and/or surgery within the past six (6) months.
- Appointment blocks will be applied who have been sent a warning letter and receive one additional no show within the same six month.
- We have the right to reschedule appointments because of refusal to pay co-pays or nominal charges at check-in.
Family Medicine, OB/GYN, & Behavioral Health Clinics

Medical patients or their guarantor are responsible for the following:
- Pay amount due for visits at check-in.
- Call the Patient Financial Counselor before your appointment to set up a payment plan if you cannot pay at check-in. Call the Patient Financial Counselor at (252) 522-9800.
- The co-pay or nominal charge you pay at check in is for the office visit only. Your provider may order more services like vaccines, lab work, ultrasounds, or procedures. These services are not part of the office visit charge. Charges for these services bill to your account. You will see these charges on your monthly billing statement. Your monthly billing statement is due for payment when you receive it.
- Bring forms with you to your office visit or pay a $10.00 fee for forms we complete outside office visits.
- Prenatal care includes office visits and delivery charges. Providers also order lab work and ultrasounds during the pregnancy. Prenatal patients must set up a payment plan for estimated prenatal and hospital care during the first prenatal visit.
- We provide circumcisions for male infants at UNC Lenoir Hospital and in our office. Circumcision charges are due in full before the appointment. NC Medicaid and NC Health Choice do not pay for circumcisions.

Patient Financial Policy continued
- For OB/GYN surgeries: Set up a payment plan with our Financial Counselor for your planned surgery and pay at least 50% of the charge before to the surgery. We will reschedule nonemergency surgeries if 50% of the surgery charge has not been paid 3 days before the surgery date.
You will pay remaining payment plan amounts timely after surgery.

If our provider performs emergency surgery, set up a payment plan with our Financial Counselor during your first office visit after the emergency surgery and pay all payments on time.
- For in office procedures – Family Medicine & OB/GYN Clinic: Pay the procedure charge when you check in for the procedure appointment.
DENTAL CLINIC

Dental patients or their guarantor are responsible for the following:
- Pay charges for your first exam and x-rays at check-in.
- Tell us if you have had dental x-rays at a different practice in the last 12 months. Dental insurance plans will not pay for some dental x-rays more than one time in a 12-month period.
- Your dentist creates a dental treatment plan during your first visit. The treatment plan will give an estimate of the charges for planned services in your treatment plan.
- After your first visit, pay charges at check-in for the services that you will receive during the appointment. We will reschedule your appointment if you cannot pay charges at check-in.
- The services on your dental treatment plan may change during your appointment. Your dental provider will let you know if the service changes. Additional charges for the service bills to you. Payment is due when you receive the monthly billing statement.
- Major dental work and procedures like dentures, crowns, and root canals require payment of 50% of the charge by the appointment date. The remaining 50% account balance is due by the appointment date to receive the denture or crown.
- You must pay your account balance in full before to receiving nonemergency dental care. If your account balance is not paid, you will be rescheduled.
- If you have dental insurance, you are must tell us about services you have had at other dental practices. If you do not tell us about dental services that you have had at other dental practices and your dental insurance denies payment, you will are responsible for paying for the services.
I acknowledge that I have read and understand Kinston Community Health Center, Inc.'s Patient Financial Policy. I agree to the comply with the Kinston Community Health Center, Inc.'s Patient Financial Policy.*

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Patient/Legal Guardian Signature
Signature Date

MonthDayYear
DateHourMinutesAM/PM Option

No Show and Late Policy
No Show and Late Policy

Kinston Community Health Center, Inc. is committed to providing all patients with exceptional care. We try to educate patients on the effects of no shows and late arrivals. We manage the effects of no shows and late arrivals which assures proper patient care and accessibility for all patients.

Appointment Confirmation

Kinston Community Health Center, Inc. provides appointment reminders to patients as a courtesy however it is the responsibility of the patient to remember their scheduled appointment date and time. Appointment reminders offered may include:
- Appointment Cards
- Automated and/or Manual Reminder Calls
- Automated Reminder Texts
- Messages left on answering services or with persons authorized by the patient to receive protected health information
Kinston Community Health Center, Inc. will attempt to contact each patient two (2) business days before a scheduled appointment to confirm the visit. If the Kinston Community Health Center, Inc. representative or automated calling service attempting to confirm the appointment is unable speak with the patient to confirm the appointment, a message will be left if a messaging service is available. If a message is left on a messaging service, it will be the patient’s responsibility to contact Kinston Community Health Center, Inc. to confirm the appointment.

Appointment Cancellation or Rescheduling

In order to facilitate scheduling, patients are asked to cancel and/or reschedule appointments at least twenty four (24) hours prior to their scheduled appointment time.

Patient visits that are not cancelled and/or rescheduled by the patient prior to their scheduled appointment date and time will be marked as a no show appointment.

Non Arrival at Appointment Date and Time

Patients are expected to arrive before or at scheduled dates and times. Patients that have not checked in before or at their scheduled appointment date and time are marked as no shows.

Vacating Waiting Area/Exam Room

Patients who leave the facility before or after checking in and are not present at appointment time when clinical staff attempt to retrieve the patient from the waiting area or treat the patient in an exam room are marked as no shows.

Late Arrivals

Patients arriving after their scheduled appointment date and time to check in are considered late and their visit is marked as a “no show.” Late arrivals will be accommodated as the schedule and available

No Show and Late Policy continued
resources permit, but may be rescheduled if the schedule availability and clinical resources cannot permit a same day accommodation. If a late patient is accommodated, the “no show” will be taken off of the visit.

A patient is not considered a late arrival if they are not checked in before or after their scheduled appointment time due to internal operational delays.

Warning Letter

A warning letter will be sent to patients with an excessive no show history; this is defined as follows:
- Two (2) or more no show visits within the past six (6) months for all routine and sick medical and dental appointments.
- One (1) or more no show visits for major and/or surgical dental visits within the past six (6) months.
- One (1) or more no show visits for medical procedure and/or surgery within the past six (6) months.
Appointment Block

Appointment blocks will be applied to patients who have been sent a warning letter and receive one additional no show within the same six months.

Once an appointment block is applied to a patient account it will remain in place for six (6) months.

Patients with an appointment block on their account will not be permitted to fill a scheduled appointment slot, but may fill a same day access slot (based on availability) for acute/urgent visits.

Dismissal Due to Chronic No Shows

A patient with six (6) or more no show visits within a twelve (12) month period may be dismissed by a Chief Medical Officer or Chief Dental Officer.

Patients have the right to appeal this decision by writing a letter explaining their reasons for the no shows to: Chief Operating Officer, Kinston Community Health Center, 324 N Queen Street Kinston, NC 28501.

Patient/Guarantor Acknowledgement

An employee of Kinston Community Health Center, Inc. reviewed this policy with me. My questions about this policy were answered. I agree to comply with the terms of this policy.
I acknowledge that I have read and understand Kinston Community Health Center, Inc.'s Scheduling, Missed/No Show Appointment Policy. I agree to the comply with the Kinston Community Health Center, Inc.'s Scheduling, Missed/No Show Appointment Policy.*

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Patient/Legal Guardian Signature
Signature Date

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Patient Rights and Responsibilities
INTRODUCTION

Kinston Community Health Center, Inc. (KCHC) patients have a fundamental right to consider care that safeguards their personal dignity and respects their cultural, psychosocial, and spiritual values. The organization provides information in a manner tailored to the patient’s language and ability to understand. KCHC has written policies on patient rights and privacy practices with the purpose to improve quality care by emphasizing patient’s rights and responsibilities and to ensure care is provided in an ethical manner.

PATIENT RIGHTS
1. The patient has the right to affordable medical treatment regardless of race, religion, gender, national origin, marital status, age, or disability.
2. Privacy and also has the right to access, request amendment to and obtain information on disclosures of his or her health information, in accordance with law and regulation.
3. Confidentiality of his or her medical records. A patient may or may not approve the release of any information in the medical records, to insurance companies or other doctors, except when this is required by law. Original charts are considered the property of KCHC.
4. Be treated with dignity and respect. The staff respects the patient’s mental, social, spiritual, and cultural values about health, illness, and injury.
5. Know what his or her illness is; to know treatment options, the advantages and the disadvantages of each; to help make decision about the treatment that he or she may receive; and to know that complications the treatment is likely to cause in a language that is easily understood by the patient.
6. Receive from his provider information necessary to give informed consent prior to the start of any procedure and/or treatment. Patients who are unable to fully participate in treatment decisions have the right to be represented by parents, guardians, family members, or other conservators.
7. Refuse treatment to the extent permitted by the law and to be informed of the medical consequences of his actions.
8. Expect that within its capacity KCHC must make a reasonable response to the request of the patient for services. KCHC must provide evaluation, service, and/or referral as indicated by the urgency of the case.
9. Obtain information as to the relationship of KCHC to any other health care and educational institutions as his or her case is concerned.
10. Expect reasonable continuity of care. He or she has the right to know in advance what appointment times and providers are available.
11. Examine and receive an explanation of his or her bill regardless of the source of payment.
12. Know what KCHC rules and regulation apply to his or her conduct as a patient.
13. Be fully informed about the services available at KCHC.
14. Be fully informed about the provisions made for non-business hour emergency coverage.
15. Voice grievances and recommend changes in polices and services.
16. Consult with another provider.
17. Be given the names, qualifications, and experience of provider’s and other KCHC staff who are directly involved with the patient’s medical care.
18. Be advised of nay teaching or research to be performed by KCHC that may affect the patient’s care. A patient has the right to refuse to participate in any such projects.
19. The appropriate assessment and management of pain.

Patient Rights and Responsibilities continued
PATIENT RESPONSIBILITIES
1. The responsibility of the patient will be to keep appointment and notify the KCHC in advance when unable to keep the appointment.
2. Follow the medical provider plan of care.
3. Seek clarification when necessary to fully understand your health problem and the proposed plan of care.
4. Provide complete accurate information about your identity, demographics, insurance and answer other reasonable questions that will assist KCHC in providing appropriated care and obtaining payment. This includes reviewing and signing all necessary consent, financial agreements or totter documents required by the facility.
5. Bring Medicaid or Medicare card and any other insurance cards at each visit.
6. Provide accurate information about your present illness, medication, past medical or health history including any hospitalizations or any changes in your condition.
7. Supervise your children, both inside and outside the facility. Parents will be held responsible for the actions of their children. Children under 12 should not be left unsupervised.
8. Mange financial arrangements regarding your medical bill at the time of service.
9. Conduct yourself in a courteous, friendly. And respectful manner toward fellow patient and members of the staff. Threatening, violent, abusive, disruptive or loud behaviors are not tolerated. KCHC reserves the right to ask the patient, family, and guest to leave or be removed from the property.
10. Comply with no alcohol, drugs, and/or weapons on the premises. Anyone who arrives at the center under the influence of alcohol, illicit drugs and unauthorized use of controlled substances and does not require urgent care will be asked to leave. Law enforcement may be contacted for assistance.
11. Patients are expected to arrive at or before scheduled appointment times.
12. If a patient is late for a scheduled appointment this will be considered as a No Show. However, late arrivals will be accommodated as the schedule and available resources permit
13. If a patient leaves the facility after checking in, this will be considered a No Show
14. Patients are expected to reschedule appointments at least 24 hours prior to the appointment.
15. The patient will receive a reminder call 2 days prior the scheduled appointment; if a voicemail is left, the patient is expected to call back and confirm the appointment by 3:00 pm on the business day prior to the scheduled appointment day. If patient does not call to confirm, it will be considered a No Show.
16. Patients with a history of excessive No Show visits will be blocked from scheduled appointment slots for a period of 6 months:3 or more No Show visits in past 6 months
  
  - 3 or more No Show visits in past 6 months
  
  - 1 or more No Show visits for major/surgical dental visit in past 6 months
  
  - 1 or more No Show visits for medical procedure or surgery in the past 6 months
  
  - 6 or more No Show visits within a 12-month period may be dismissed from the Center
PATIENT FINANCIAL RESPONSIBILITIES
1. The patient is financially responsible for any services received at KCHC that are not covered by an insurance company, Medicaid, Medicare, or any other commercial insurance that has been chosen to pay for the services provided at each visit.
2. The amount of the visit will be determined after the Doctor’s visit. The cost of each visit may vary depending on what is ordered during my visit.
3. As a courtesy to the patient, KCHC will file your insurance and get authorization for procedures. However, it is your responsibility to give us all the necessary insurance information at the time of service. You may also want to verify with your insurance company that approval was given. KCHC will need a copy of your insurance card at each appointment.
4. If insurance authorization cannot be obtained, you are responsible for the charges.
5. Co-payment is due at each appointment and before any procedure is performed.
6. KCHC is not a free clinic and we must collect from all of our patients in order to continue to provide services to our community.
7. If referral is needed by your primary doctor, please bring it with you or have the doctor to fax to our office prior to your visit.
I acknowledge that I have read and understand Kinston Community Health Center, Inc.'s Patient Rights and Responsibilities. *

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Patient/Legal Guardian Signature

Notice of Privacy Practices

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Notice of Privacy Practices continued

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I acknowledge that I have received Kinston Community Health Center, Inc.'s Notice of Privacy Practices.*

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Patient/Legal Guardian Signature

Patient Acknowledgements

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Patient Acknowledgements

I understand that Kinston Community Health Center, Inc. is a Federally Qualified Health Center (FQHC).

I understand that Kinston Community Health Center, Inc. is not a free clinic and I or my guarantor will be responsible for paying for the portion of the charges for my care that are not satisfied by insurance and/or the Sliding Fee Discount Program.

I have been made aware of the programs Kinston Community Health Center, Inc. offers to assist me with my healthcare and prescription costs including 340B and the participating pharmacies, Medication Assistance Program, and the Sliding Fee Discount Program.

I have provided information to Kinston Community Health Center, Inc. for all insurance coverages that I have for medical, maternity, dental, mental health, and substance abuse services.

It is my responsibility to contact Kinston Community Health Center, Inc. to update my information including addresses, phone numbers, emergency contacts, insurance status, family size, and income.

I authorize and direct Kinston Community Health Center, Inc. providers as they deem necessary to perform any necessary diagnostic tests and evaluations on me as deemed medically indicated and provide me with treatment and prescriptions, including administering medication to me. I understand that any such test or treatment provided to me will be explained to me prior to its performance and that I may ask questions about such test or treatment.

I authorize the release of any medical information necessary to process claims. I also authorize payments under my insurance programs to be made directly to Kinston Community Health Center, Inc. for any services furnished to me. I further permit copies of the authorization to be used in place of the original.

I understand that action will be taken if any of the information that I have provided is determined to be false.
Patient/Legal Guardian Signature*

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PATIENT SIGNATURE DATE

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	Insurance Company Name	Insured Name	Insured DOB	Policy Number	Relation To Insured
Policy 1
Policy 2
Policy 3

Patient Registration Form

Patient Registration Form

Emergency Contact Information

Medical/Dental Plan Information - Medicaid/Medicare

Medical/Dental Plan Information - Commercial/Private Insurance

Parent/Guardian Information

Patient Defined Information

Employer Information

Patient Demographic Form

Pharmacy Information

Patient Care Needs - Medical

Non Disclosure of Medical Records

Authorization to Request Protected Health Information

I hereby request my medical information from:

Patient Care Needs - Dental

Patient Care Needs - Behavioral Health

Authorization To Release Medical Information

Authorization To Release Medical Information continued

Sliding Fee Discount Program

Sliding Fee Discount Program Application

Patient Financial Policy

Patient Financial Policy continued

Patient Financial Policy continued

No Show and Late Policy

No Show and Late Policy continued

Patient Rights and Responsibilities

Patient Rights and Responsibilities continued

Notice of Privacy Practices

Notice of Privacy Practices continued

Patient Acknowledgements

	First Name	Last Name	Relationship to Patient
1
2
3