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.

Authorization

1. I understand that this information will expire one year from the date I have signed this form, unless otherwise specified.
2. I understand that I may revoke this authorization at any time by notifying the provider and/or practice in writing. The revocation will be effective on the date of receipt of written notification of revocation except to the extent action has already been taken upon this Authorization for Release of Protected Health Information.
3. I understand the information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by Federal Privacy regulations.
4. I understand that my health care and payment for my health.care will not be affected if I do not authorize release of my protected health information.

Internal Use Only

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

We receive federal grant funds that support the provision of care to our uninsured and underinsured patients.

We are required to collect and report the information on this form annually for every patient that we serve.

The responses on this form are combined and reported as percentages and total patients with similar reponses. No external agency is able to identify your individual responses in our report.

This information is kept confidential at all times.

Homeless Status

We ask this question to provide information to our providers about how your living situation may affect your health.

Answer Yes if any of the following is true:

• You do not have housing.
• You are living in a homeless shelter.
• Your are living in temporary or transitional housing.
• You do not have housing because you have been in jail, prison, or the hospital and you do not know where you will live after discharge.

Migrant Farmworker

We ask this question to provide information to our providers about how your work may affect your health.

Answer Yes if the following is true:

• You or a member or of your family with whom you reside moved in the past two years to another area (established a temporary home) in order to work mainly in agriculture.

Seasonal Farmworker

We ask this question to provide information to our providers about how your work may affect your health.

Answer Yes if the following is true:

• You or a member or of your family with whom you reside worked in the past two years primarily in agriculture without moving from your home.

Language

We ask this question to provide information to our providers about possible language barriers and to arrange interpretation services prior to your visit. 

You may ask for an interpreter at any time during your visit. 

Public Housing

We ask this question to provide information to our providers about your housing environment and how it may affect your health.

Veteran Status

We ask this question to make sure our providers know your veteran status and we make you aware of any veteran programs and/or services that may be available.

Primary Medical Coverage

We ask this question to make sure our providers know your your primary medical coverage, if applicable. Many medical payers have different rules about services and requirements to seek approval prior to certain services. 

Please answer "yes" or "no" to tell us if the patient has each coverage type below:

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.

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.

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.

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.

Patient Accounts

Our Patient Accounts staff will assist you with adding and updating insurance information, Sliding Fee Discount Plan applications, payment arrangements, answer billing questions, and Affordable Care Act insurance coverage applications. Call our Patient Accounts department at (252) 522-4350, select option 4 and then option 1.

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 on the 10th 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.

We have staff who are available to assist you with determining our eligibility for Affordable Care Act plans in our Patient Accounts department. You may also complete this process by visiting www.healthcare.gov.

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

 Payment Arrangements

Our Patient Accounts staff are on-site from 8am – 5pm to help you with payment arrangements if needed.

Patient Refunds

If you pay more than your account balance, you may have an account credit. We apply all credits to outstanding balances from previous visits. If there are no previous visits with balances and no upcoming visits within 90 days, 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 Patient Accounts department set up a payment plan to avoid collection activity.

Refusal to Pay

Kinston Community Health Center, Inc. reserves the right to reschedule an appointment due to 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 your co-pay or nominal charge for the office visit at check-in.

Please note: 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.

Call Patient Accounts before your appointment to set up a payment plan if you cannot pay at check-in. 

Bring forms with you to your office visit or pay a $10.00 fee for forms we complete outside office visits.

For Pregnant Patients:

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 trimester.

Please note: 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.

For OB/GYN surgeries:

Set up a payment plan with Patient Accounts for your planned surgery and pay at least 50% of the charge before to the surgery. We will reschedule elective 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 Patient Accounts 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

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.

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.

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 be responsible for paying for the services.

Appointment Scheduling

We schedule an appointment for you based on the date, time, and provider you prefer 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 can send appointment confirmation messages to you by phone, text, or email.
• When you receive an appointment confirmation message, respond to the message and remember the arrival time given in the message.
• 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.

No Show Appointments

We highly discourage missed appointments. When you miss an appointment, you are not receiving the care you need and another patient who requires care is unable to take that appointment slot. If you need to cancel and/or reschedule an appointment, please call us at 252-522-9800 at least 24 hours before your appointment.

Missing multiple appointments will result in you only being able to be seen as a walk-in patient. This is done to ensure availability of appointments for all patients. Please be advised that under the following circumstances you will be seen only as a walk-in patient:

If you miss 3 or more appointments over 6 months you will be seen as a walk-in patient only. We will not schedule an appointment for you for 6 months.

If you miss 1 appointment for the visit types below you will be seen as a walk-in patient only. We will not schedule an appointment for you for 6 months.

• Medical procedure
• Major or surgical dental procedure
• OB or GYN procedure or surgery

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 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.

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.