Family HealthCare Mobile Unit Intake Form

Disclaimer: If you do not want to complete this registration and consent form electronically, please complete and sign a physical consent form instead. To obtain a physical consent form for services on Family HealthCare's Mobile Unit, please contact your school/program's health office or contact us at 701-271-6379.

PATIENT INFORMATION

Patient's First Name

Patient's Middle Name

Patient's Last Name

Date of Birth (DOB)

Patient's Social Security Number (SSN)

Address

City

State

ZIP Code

Primary Phone Number

Secondary Phone Number

Email Address to Contact Guardian

Does Patient require interpreting services?

Yes No

If Other, what Language?

Additional Information

Which of the following describes the patient?

Hispanic/Latino/Spanish Origin Non-Hispanic or Latino Mexican, Mexican American Cuban Puerto Rican Other Hispanic/Latino/Spanish Choose not to Disclose

Is the patient a Veteran?

Yes, Veteran Not a Veteran Declined to Answer

What level of education has the patient completed?

High School College Degree Graduate Degree None of the Above Declined to Answer

Farm work status of patient:

Seasonal Year round Migrant None of the Above Declined to Answer

Is the patient homeless?

Yes No Declined to Answer

If homeless, where does the patient stay?

Homeless Shelter Transitional Housing Doubling Up Street Supportive Housing Other

If other, where?

Patient's Gender Identity

Male Female Transgender male to female Transgender female to male Other/Neither male or female Declined to Answer

Patient's Identifies as:

Straight Lesbian or Gay Bisexual Something else Do not know Declined to Answer

Patient's Preferred Pronouns:

He/Him/His She/Her/Hers They/Them/Theirs Other Declined to Answer

FINANCIALLY RESPONSIBLE/GUARANTOR INFORMATION

Enter the name of person FINANCIALLY responsible for this patient

Guarantor's First Name

Guarantor's Middle Name

Guarantor's Last Name

Guarantor's Date of Birth (DOB)

Guarantor's Social Security Number

Address

City

State

ZIP Code

Primary Phone Number

Secondary Phone Number

Does Guarantor/Guardian require interpreting services?

Yes No

If Other, what Language?

Relationship to Patient

Mother Father Legal Guardian Self Foster Parent Other

If other, what is your relationship to patient?

EMERGENCY CONTACT

Emergency Contact same as Guarantor

First Name

Last Name

Date of Birth (DOB)

Cell Phone Number

Home Phone Number

Relationship to Patient

INSURANCE COVERAGE

Do you have insurance coverage?

Yes No, I have no insurance coverage and will be paying fee for service.

Insurance carriers will be billed for services provided. However, you are ultimately responsible for payment for treatment and care. Please fill out the insurance information below if applicable.

Personal information will be kept confidential and will not be shared with any person who is not directly involved in the care as a part of the Health Insurance Portability and Accountability Act (HIPAA).

Primary Insurance Coverage

Method of Providing Primary Insurance Information

Upload Photo of Insurance Card Manually Enter Insurance Information

Insurance Card Photo Please submit photos of both the front and back of your insurance card.

Add file

Please upload a file

Insurance ID # / Medicaid ID #

Name of Insurance

Group Number

Subscriber Name

Subscriber Date of Birth

Subscriber SSN

Policy ID Number

Insured Employer

Insured Employer Phone #

What Type of Insurance Coverage?

Medical

Dental

Other

If Other, what type?

Secondary Insurance Coverage

Method of Providing Secondary Insurance Information

Upload Photo of Insurance Card Manually Enter Insurance Information

Insurance Card Photo Please submit photos of both the front and back of your insurance card.

Add file

Please upload a file

Insurance ID # / Medicaid ID #

Name of Insurance

Group Number

Subscriber Name

Subscriber's Date of Birth

Subscriber's SSN

Policy ID Number

Insured Employer

Insured Employer Phone #

What Type of Insurance Coverage?

Medical

Dental

Other

If Other, what type?

Verification of Patient Registration Information

As the patient or patient's guardian:

By electronically signing below, you verify all registration/demographic/insurance/etc. information above is true and correct.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient/Guardian/Legal Representative

Date

ACCESS PLAN ELIGIBILITY

Are you interested in signing up for our discounted insurance program? Please indicate:

I want to apply for Family HealthCare's Access Plan/Sliding Fee Scale I decline to provide information/do not meet income requirements for Family HealthCare's Access Plan/Sliding Fee Scale

If you indicated that you would like to sign up for our discounted insurance program, a Family HealthCare representative will contact you at your provided phone number on this form to further assist in the application process. Please call us at 701-271-3344 with any questions.

Family HealthCare Access Plan Eligibility Chart

Family Size

Enter 0 if you do not want to disclose your family size

Gross Annual Income of Household

Enter 0 if you do not want to disclose your household's annual income

If eligibility is indicated above, a full application and income verification are required to determine approval. Family HealthCare staff would be pleased to assist with the application process.

By initialing, I understand that Family HealthCare has a sliding fee discount program, and I can apply at any time.

Patient's/Guarantor's Initials

Initial to indicate you have completed this section, to participate or decline to provide information

PATIENT FINANCIAL RESPONSIBILITY & AUTHORIZATION

Thank you for choosing Family HealthCare. We are committed to providing you with the highest quality of service and care. We ask that you read and sign this form to acknowledge your understanding of our patient policies.

Patient Acknowledgment and Authorization

As the patient or patient's guardian:

I have reviewed the Notice of Privacy that describes the policies of Family HealthCare related to the use of care records and how to get access to this information.
I authorize Family HealthCare and its providers and staff to provide records acquired during my care to my insurance carrier, third-party payers, and other physicians or healthcare entities that participate in my care.
I understand that Family HealthCare respects patient confidentiality and only releases information in accordance with state and federal law.

Patient Financial Responsibility

As the patient or patient's guardian:

I am ultimately responsible for payment for treatment and care.
I have provided the most correct and updated insurance information and authorize the assignment of payment directly to Family HealthCare and associated entities for all insurance benefits payable or services rendered.
I understand that I am responsible to pay copayments due at the time of service and amounts for coinsurances, deductibles and non-covered services are due 30 days from receipt of my billing statement.
I will agree to a payment plan if I am not able to pay the billed balance in full and understand that I may be refused service or sent to collections if I am not willing to pay the for costs of services I have received.
I realize that certain tests and lab services are sent outside of Family HealthCare and I will be billed separately by the outside entity and these balances are also my responsibility.

Consent for Treatment

As the patient or patient's guardian:

I hereby request and authorize Family HealthCare to accept me as a patient and provide the services and care identified in the course of assessment and evaluation.
I understand Family HealthCare partners with teaching institutions and treatment is closely supervised by licensed providers and staff.
I understand that this form will be a part of my records until such time as I may choose to revoke this acknowledgment. If I am not the patient, I represent that I am authorized by law to act on the patient’s behalf.

No Show/Missed Appointment

Understand it is required to give 24-hour notice when canceling an appointment. If there are two (2) or more No Show/Missed appointments within a six (6) month period, I may not be able to request a future appointment. Notification will be sent via text (SMS) and a letter when a missed appointment occurs.

Verbal Permission about my Protected Health Information (PHI)

Permission is given to Family Healthcare to discuss and/or leave messages about my PHI allowed by law via telephone, patient portal and/or by text messages (SMS).

Photo Consent/Release: I consent to the use of pictures, videos, or audio recordings of my child for program promotion. This consent will be valid for 12 months from signature and submission of form.

Yes No

ACKNOWLEDGMENT

I have initialed the Patient Financial Responsibility & Authorization section of this intake form. By doing so, I acknowledge that I have read all of the aforementioned statements and will abide by the same, and if I do not, this may disqualify me from receiving care from Family HealthCare.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient/Guardian/Legal Representative

Date

AUTHORIZATION TO RELEASE PATIENT INFORMATION

Patient's First Name

Patient's Middle Name

Patient's Last Name

Date of Birth

I hereby give permission to Family HealthCare to verbally discuss and/or leave messages about my Protected Health Information (PHI) indicated on this authorization form. I am comfortable with Family Healthcare leaving general messages at these telephone numbers, patient portal and/or by text message (SMS).

PHI that may be discussed and/or messages left may include but not limited to:

Appointment reminders (provider name, location, time, and date)
Test and procedure general information
Medication and Prescriptions
Billing or payment information
Referral information
Other general health information

Marking below indicates authorization or decline:

Home Number

Yes No

Cell Number

Yes No

Work Number

Yes No

Family Healthcare is authorized to discuss my care with:

Name

Date of Birth

Relationship:

Name

Date of Birth

Relationship:

Name

Date of Birth

Relationship:

I understand the above authorizations will remain in effect until further written notice is received.

PLEASE NOTE: This release of information does not include written record requests to/from other medical offices, requests by insurance companies or other outside agencies. Specific releases will need to be obtained by the patient for these purposes.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient/Guardian/Legal Representative

Date

AUTHORIZATION FOR MEDICAL/DENTAL CARE TO MINORS or ADULTS WITH DISABILITIES

For families who are ongoing patients of Family HealthCare, it may be more convenient to have prior authorization for medical/dental care delivered to minors/adults with disabilities if for some reason the parent/guardian is unable to be present. Please review the following authorization for treatment and complete the information if you want to pre-authorize treatment. Authorized person(s) MUST be 18 years of age or older.

AUTHORIZATION

Are you filling out this form for a child/minor or an adult with disabilities?

Yes No, filling out for myself

Are you the legal guardian(s)?

Yes No

If no, you cannot complete this form. Please call us at 701-271-6379.

Authorization:

I do NOT authorize Family Healthcare and its personnel to provide any medical/dental services to my minor without my presence except for in a life-threatening circumstance I authorize Family Healthcare and its personnel to deliver medical/dental care to my minor/adult listed below for whom we are the legally responsible party:

Name of Minor/Adult with Disability

Date of Birth

Social Security Number

Person(s) authorized to accompany minor/adult to clinic if legal guardian is unavailable:

Name

Relationship to child/family:

Name

Relationship to child/family:

Name

Relationship to child/family:

PARENT/GUARDIAN SIGNATURE

I understand that I am giving permission to Family HealthCare to treat the above-named minor/adult with a disability in the event that he/she presents to the clinic with one of the authorized individuals listed above, and that permission is granted to forward pertinent medical or other information from this visit to the insurance company if applicable.

I further understand that parent/guardian must be present for any non-emergent medical/dental surgical procedures including but not limited to tooth extractions and Root Canals. Family HealthCare will do our best to notify guardians of such procedures/paperwork before the appointment date.

I UNDERSTAND THAT THIS AUTHORIZATION WILL REMAIN IN EFFECT FOR ONE (1) YEAR OF SIGNATURE DATE.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient/Guardian/Legal Representative

Date

Location of Patient Requesting Services

Program/School District/Organization Where is you/your child enrolled at/program involved with?

Fargo Public Schools Moorhead Area Public Schools Dilworth-Glyndon-Felton Public Schools West Fargo Public Schools HeadStart/SENDCAA Richland #44 School District Other

Community Vaccine Events

Moorhead Area Public Schools location enrolled at?

Dorothy Dodds Elementary

Ellen Hopkins Elementary

Probstfield Elementary

Robert Asp Elementary

S.G. Reinertsen Elementary

Horizon Middle School

Moorhead High School

Moorhead Alternative Learning Center

Teacher's Name?

Dilworth-Glyndon-Felton Public Schools location enrolled at?

DGF Elementary

DGF Middle School

DGF High School

Teacher's Name?

HeadStart/SENCAA location enrolled at?

Central Head Start

South Head Start

West Fargo Head Start

Kappel Head Start

Early Head Start

HeadStart/SENDCAA

Other Program/School/Organizations?

Please enter "NA" if this does not apply

Contact for more information on mobile unit services.

Richland #44 Schools location enrolled at?

Richland Elementary

Abercrombie, ND

Richland Jr./Sr. High

Colfax, ND

Services Requested on Family HealthCare's Mobile Unit

Services Requested on Mobile Unit: Fargo Public Schools, select at least one option

Immunizations

Tdap, MenACWY, Influenza, etc.

Optometry

vision exams

Services Requested on Mobile Unit: Jefferson Elementary, select at least one option (in addition to previous selection)

Medical

wellness exams

Parent/Guardian, how will you be attending the Jefferson Elementary Medical visit? Family HealthCare requires the guardian be present for a wellness exam to allow for guardian-provider communication.

In-Person

Please list the preferred time for you or your child's appointment.

Video Call (Doximity)

Please list the best phone number to reach you at. This option will utilize a video call on your smartphone.

Preferred time for In-Person attendace:

Preferred phone number for video call attendance:

Name of preferred Pharmacy:

Where can we send your child's prescriptions to if the provider indicates they are needed?

Address of preferred Pharmacy:

Where can we send your child's prescriptions to if the provider indicates they are needed?

Services Requested on Mobile Unit: Moorhead Area Public Schools, select at least one option

Dental

cleanings, exams, x-rays, fluroride, follow-up care, etc.

Services Requested on Mobile Unit: Dilworth-Glyndon-Felton Public Schools, select at least one option

Dental

cleanings, exams, x-rays, fluroride, follow-up care, etc.

Services Requested on Mobile Unit: Richland #44 School District, select at least one option

Dental

cleanings, exams, x-rays, fluroride, follow-up care, etc.

Services Requested on Mobile Unit: West Fargo Public Schools, select at least one option

Immunizations

Tdap, MenACWY, Influenza, etc.

Services Requested on Mobile Unit: Headstart SENDCAA, select at least one option

Dental

cleanings, exams, x-rays, fluroride, follow-up care, etc.

Optometry

vision exams

Services Requested on Mobile Unit: Other Programs, select at least one option

Immunizations

Tdap, MenACWY, Influenza, etc.

Agreement and Signature of this form gives consent for all services provided by Family HealthCare. By selecting specific services here, you are requesting which services you would like your child/yourself to receive while on the mobile unit. This will serve as an Annual Registration form for all visits throughout Family HealthCare.

Please note: not all services requested are available at all locations we service in the area.

If you have questions about what healthcare services Family HealthCare has available, please reach out to your program/school district's health office or call our mobile unit department at 701-271-6379.

HEALTH HISTORY

Patient's First Name

Patient's Middle Name

Patient's Last Name

Date of Birth

Date of last Dental Visit

Within the last 12 months More than a year ago Never

Is your child allergic to anything?

Yes No

If yes, what?

Is your child taking any medication?

Yes No

If yes, what?

Does your child have any medical conditions such as heart disease, asthma, anemia, hay fever, hepatitis, cancer, seizures, diabetes, etc.? Or any other medical condition?

Yes No

If yes, what?

Does your child/yourself wear glasses or have worn glasses in the past?

Yes No

If yes, list the dates to the best of your knowledge:

Immunization Screening Questions

Are you/your child sick today?

Yes No

Do you/your child have allergies to medications, food, a vaccine ingredient, or latex?

Yes No

If yes, what?

Have you/your child ever had a serious reaction after receiving a vaccine?

Yes No

If yes, what?

Have you/your child ever felt dizzy or faint before, during, or after a shot?

Yes No

Are you/your child anxious about receiving vaccines?

Yes No

Do you have any of the following: long-term health problem with heart, lung, kidney, or metabolic disease (eg. diabetes), asthma, a blood disorder, no spleen, a cochlear implant, or a spinal fluid leak? Are you on long-term aspirin therapy?

Yes No

If yes, what?

Do you/your child have cancer, leukemia, HIV/AIDS, or any other immune system problem?

Yes No

If yes, what?

Do you/your child have a parent, brother, or sister with an immune system problem?

Yes No

If yes, who?

In the past 6 months, have you taken medicines that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis, or had radiation treatment?

Yes No

If yes, what?

Have you/your child had a seizure or a brain or other nervous system problem?

Yes No

If yes, what?

Have you/your child ever been diagnosed with a heart condition (myocarditis or pericarditis) or have you had Multisystem Inflammatory Syndrome (MIS-C) after an infection with the virus that causes COVID-19 (COVID)?

Yes No

If yes, what?

In the past year, have you/your child received immune (gamma) globulin, blood/blood products, or an antiviral drug?

Yes No

If yes, what?

Are you/is your child pregnant or is there a chance they could become pregnant during the next month?

Yes No

Have you/your child received any vaccinations in the past 4 weeks?

Yes No

If yes, what?

IMMUNIZATIONS REQUESTED

Immunization resources for parents/children:

Vaccine Information Statements (VIS) for Immunizations Requested on Mobile Unit:

To view Vaccine Information Statements (VIS), please select vaccines requested above.

Influenza VIS

HIB VIS

MMR VIS

Meningococcal ACWY VIS

Varicella - Chicken Pox VIS

A copy of this completed form is available upon request.

Your information will be encrypted.

Family HealthCare

Family HealthCare (FHC) is a family-oriented primary care clinic that provides a wide variety of medical services for patients in the Fargo-Moorhead area.

Call our Main Clinic at 701-271-3344, Mobile Unit Questions? 701-271-6379, Medical Records Fax - 701-271-3347
famhealthcare.org
Family.HealthCare.Fargo
family.healthcare.fargo
301 NP Avenue, Fargo, North Dakota, 58102