Demographics Form - Manteo Community Health Center

Patient Information

Patient Name*

First Last

Patient Preferred Name*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Physical Address*

Street Address Address Line 2 City State ZIP Code

Primary Telephone Number*

Secondary Telephone Number

Email*

Social Security Number

Date of Birth*

Sex at Birth*

(check what applies)

Male
Female

Gender Identity*

(check what applies)

Male
Female
Trans Male (FTM)
Trans Female (MTF)
Other
I Choose Not to Disclose

Sexual Orientation*

(check what applies)

Straight (not Gay)
Gay or Lesbian
Bisexual
Something Else
Don't Know
I Choose Not to Disclose

Marital Status*

(check what applies)

Race*

(check what applies)

I Choose Not to Disclose
Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian
White/Caucasian
Pacific Islander

Ethnicity*

(check what applies)

Hispanic or Latino
Not Hispanic or Latino
I Choose Not to Disclose

Language Preference*

(check what applies)

English
Spanish

Highest Level of Education*

(check what applies)

Less than High School degree
High School diploma or GED
More than High School
I Choose Not to Answer this Question

Patient Occupation*

Patient is a Minor*

Yes
No

Patient is a Seafood Worker*

Yes
No

Annual Household Income*

(check what applies)

How many family members, including yourself, do you currently live with?*

Emergency Contact*

First Last

Phone Number*

Relationship to Patient*

Person Financially Responsible if Not Patient

First Last

Phone Number

Relationship to Patient

Address

Street Address Address Line 2 City State ZIP Code

What is Your Main Insurance?*

(check all that apply)

None/uninsured
Medicare
Medicaid
BCBS
Medcost
Tricare
United Health Care
Other Private Insurance

Insurance Policy / Member ID

Group ID

File Upload - Upload Pictures of Insurance Card, front and back, and Your Drivers License (front)

Please take a picture of your of your insurance card (front & back ). Please take a picture of your Drivers License (front). You can upload all the images here.

Drop files here or

Max. file size: 13 GB.

Consent

CONSENT FOR GENERAL MEDICAL TREATMENT*

I authorize the employees of OCRACOKE HEALTH CENTER (OHC) to render primary care and related services. I understand that OHC is committed to offering superior quality of care to all patients regardless of race, ethnicity, religion, sex, age, or handicap status. I understand that I will be fully informed of anticipated benefits, possible discomforts, and potential side effects prior to the performance of any medical treatment, and I release OHC from liability that may arise as the result of such treatment, unless due to sole negligence of its staff. I consent to examinations, treatments, procedures and blood tests ordered by my physician and health care providers, including blood tests for communicable diseases such as hepatitis and HIV/AIDS.

MEDICARE PATIENTS: SIGNATURE ON FILE*

I request payment of authorized Medicare benefits be made either to me or on my behalf to OCRACOKE HEALTH CENTER for any services furnished me by the listed provider / supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated on approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency. In Medicare assigned cases, the provider or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and noncovered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.

ASSIGNMENT OF INSURANCE BENEFITS*

I hereby assign all medical and / or surgical benefits, to include major medical benefits to which I an entitled, private insurance, and any other health plans to OCRACOKE HEALTH CENTER. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure the payment.

FINANCIAL POLICY FOR PAYMENT AND DISCOUNT PLAN MVP*

Services rendered are expected to be paid for on the date of service. Sources of acceptable payments are Cash, Check, Medicare, Medicaid, Champus, Private Insurance, debit card, Major Credit cards (MasterCard, VISA). If you need help paying this bill, you may qualify for the sliding fee scale discount plan MVP. The sliding fee scale is based on your household size and income. I have read, understood, and agreed to this financial policy for payment of professional fees. The patient is ultimately responsible for all professional fees.

NOTICE OF PRIVACY PRACTICES RECEIVED*

I acknowledge that I was provided with the Notice of Privacy Practices of the OCRACOKE HEALTH CENTER.

Signature*

Date*

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Patient Information

Consent

Manteo Community Health Center

Hours

Ocracoke Health Center

Engelhard Medical Center