THE P.A.T.C.H. CENTER PATIENT REGISTRATION FORM

1 Today s PATIENT sIs this yo Yes Street BoxPatient OSpouse Name: Guardian Name: Person rIs this peOccupatPatients Please iSubscribName ofapplicabPatient sIN CASEName of Theu Date: s Last Name: our legal name? No ddress: x: Occupation: Information: n Information: responsible for berson a PATIENT htion: relationship to sndicate Primaryber s Name: f Dental and/or ble): s relationship to sE OF EMERGENf local friend or ree following informsers of PreferredinfPC14 First:If not, whINSUill: Birthere? YEmployer: subscriber: SelInsurance Secondary Insusubscriber: SeNCY elative (not livingmation is requested Family Healthcformation will PAT: Mhat is your legal City: PATIENT EmployAddrAddrRANCE INFORh date: AYes No Employer lf Spouse Medicare Subscriber s SSurance (if Subelf Spouse g at same addresed by the Federacare dba Clarity Ht be used to discTHE REGIST (PleasPATM iddle: name?))

2 Yer: ress: ress: RMATION (PleAddress (if differaddress: Child SMedicaid SN Bbscriber s name:Child SIN CAss): al Government inHealthcare. Youcriminate against(conH. CENTER TRATION FORse Print) TIENT INFORMMr. Ms. Mrs. Miss(Former name):Social Secuease give yourrent): Step Child OBlue Cross BluBirth Date: Step Child OASE OF EMERR elationship tn order to monitorare not requiredtyou in any way, ntinued on back)Page 1 RM Primary CareMATION Primary Phone: urity Number: State: r insurance caOther ue Shield Policy # Other RGENCY to PATIENT : r compliance witd to furnish this in nor will be releae Provider: e Number: EmaBirth date: SecoEmplPhone NumPhone Numard to the recePrimaEmplUnited HealthcarGrouGroup no.

3 : Primary Phone th Federal laws pnformation, but aased except in agail Address: Age: ondary Phone NZIP Code: loyer Phone Nummber: mber: eptionist) ary Phone Numbloyer Phone Numre Other p # Poli# Secondprohibiting discrimare encouraged tggregate form. Sex: M F umber: mber: ber: mber: Co-payment: $ cy no.: ary Phone # mination against to do so. This Please circle one answer in each of the following categories. Ethnicity: Hispanic or Latino Not Hispanic or Latino Race: Other Pacific Islander White (not Hispanic or Latino) Asian Black/African American Hispanic or Latino (all races) Native Hawaiian American Indian/Alaska Native Refuse to Report Primary Language: English Other (Specify) Are you a veteran?

4 : YES NO Housing Status: Transitional Housing Homeless Doubling Up Own/Rent Shelter Marital Status: Divorced Single Widow Married Legally Separated Employment Status: PATIENT : Part Full Unemployed Spouse: Part Full Unemployed Number Living in Household: Income: _____ Annual Monthly Bi-Weekly Weekly Does your child qualify for the school lunch program? Yes No Insurance and PATIENT Responsibility Insurance claims are submitted on your behalf by Clarity Healthcare. If your child is on the HPS Free or Reduced School Lunch program, there will be no cost to you for services provided at the CENTER .

5 For children or faculty with insurance, we will file a claim with your insurance and you will be billed for any applicable coinsurance or deductible. Agreement to Pay for Services I authorize Preferred Healthcare dba Clarity Healthcare to release my medical information necessary to Medicaid or my insurance plan to process claims and further authorize payment of medical benefits payable directly to Preferred Family Healthcare dba Clarity Healthcare. Privacy Practice Acknowledgment I am aware that the Clarity Healthcare has a HIPAA (Health Insurance Portability and Accountability Act) Notice of Privacy Practices. I may request a copy at any time by contacting Clarity Healthcare at 573-603-1460 or download a copy at The above information is true to the best of my knowledge.

6 I authorize assignment of benefits for services received to be paid directly to Preferred Family Healthcare dba Clarity Healthcare. I understand that I am financially responsible for any balance. I also authorize Preferred Family Healthcare dba Clarity Healthcare or my insurance company to release any information required to process my claims. PATIENT /Guardian Signature _____ Date _____ Page 2 CLA Full Name ___Home AddresPhone #: ____ ___ Yes! I coninjuries, vaotherwise___ Yes! I conSome trea___ Yes!

7 I concommunit___ Yes! I con___ Yes! I conhealth infotwo agencpermitted submittingInformation excabove. The indiI understand thAbuse PATIENT Rcannot be discI consent to allodeemed necesspayments not chealthcare and I authorize the rcollection; inclurelease of preaplans, test resucollection (if apI also consent tSenior ServicesBy signing this consent. I unde_____Patient or Pare If you would likeARITY HEALTH_____ss: _____sent for me / my caccinations, chron specified by the psent for me / my catment may be desent for me / my cty resource referrasent for me / my csent to allowing Hormation for the pucies is confidential by law. The indivig the request in wrchange by these pividual may not haat my alcohol andRecords, 42 without my wow Clarity Healthcsary for my physiccovered under insu payment purposerelease of medicading the release odmission, recertifilts, or consultationplicable).

8 To allow Clarity Hes to that agency anconsent, I confirmerstand I may revo_____nt/Legal Guardiane a copy of this auHCARE /PREFSha_____child to receive menic disease managparent or guardianchild to receive delivered by a hygiechild to receive coals and outreach, achild to be transpoHannibal School Durpose of continuil and will not be diidual or the parentriting to the Superersons or agencieave access to certa/or drug treatmentR. Part 2, and the written consent uncare/Preferred Famcal and mental heaurance benefits foes. l and billing informof alcohol or drug acation, and appeans. I further authoralthcare/Preferrednd to cooperate wm I am the ___ paoke this consent at_____n Signature uthorization, pleasTHE FAMI ared Consent t_____ Alternate Phonedical care througgement, and referrn ental care through nist or assistant.

9 Unseling and/ or cand coordination oorted to appointmeistrict #60 and Claty of care and treaisclosed to any otht/guardian (if indivintendent of Schoes may be used onain services if thist records are proteHealth Insurance nless otherwise prmily Healthcare, Inalth unless otherwr these services. Imation from Clarityabuse (if applicabal information to inrize the release ofd Family Healthcawith investigations,atient / ___ paret any time with a w_____ e initial: _____ CENTLY HEALTHCAto Treat and R_____ SSN: _____ne #: _____h the Crals) Please note: the Cecase managementof outside resourceents by HPS. This arity Healthcare/Pratment. I understaher party without tidual listed above ol. nly for educationas release of informected under the fePortability and Acrovided for in the nc.)

10 To obtain emergwise specified throu also give permissy Healthcare/Prefele) information thasurance companief DMH69 Standardre to report comm providing client inent/legal guardianwritten request. _____ es _____ NTER ARE AND HARecord Disclo_____City: _____Center (examples all required and renter (Examples: ct services. (Exames and/or services permission can breferred Family Heand that all informthe prior written co is a minor) may rl, medical, and memation is not authoederal regulations ccountability Act ofregulations. gency medical or ugh written consesion to Clarity Heaerred Family Healtat may be containees or their agents d Means and DMHmunicable diseasesnformation as requn of the above liste_____ No NNIBAL SCHO osure _____ _____ Schoo: physical exams, recommended vaccleanings, x-rays, mples: one-on-one s).