To Apply For Our Sliding-Fee Program:
- Proof of household income from EVERYONE in the household who works:
- Most recent pay check stubs, (please bring at least 3-4 paycheck stubs) (Must be dated within 60 days of registration) OR
- Last years tax return
- Employer statement of income, which states gross income and frequency of pay. This letter must be DATED, SIGNED and include a TELEPHONE NUMBER.
- Award Letter received from (GOVERNMENT ASSISTANCE) only if this applies to you or anyone in your household:
- Food Stamps
- Child Support
- Social Security/ Disability
- Public Housing
- Valid Picture ID and Insurance Card if any
All information provided must be current, dated within the last 60 days.
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Healing Hands Ministries Partnership in Care Agreement
Healing Hands Ministries is pleased to be a partner with you in your healthcare. We know that managing your health includes you being involved. You, as a patient, are in control of your health. The choices that you make every day have an impact on your health. Your diet, exercise and other decisions you make impact your health as much as or more than any physician.
We are committed to educating you about your health and working with you. Having better information and taking an active role can help you make healthier decisions. We encourage you to ask questions and share ideas with our healthcare team.
We will encourage you to take an active role in your healthcare by making the following wise choices for each visit that you have:
- Always bring all medications that you are taking with you to each visit. (prescription drugs, over-the-counter medicines, vitamins, and herbal remedies and supplements)
- Make a list in advance of things that you may want to discuss at your appointment.
- Be sure to make transportation plans in advance and arrive 20 minutes early to each appointment.
- Be sure to ask questions if you don’t understand something.
- Follow the plan of treatment recommended by your physician.
- Take all medications as directed.
- Respond to all communications from the clinic.
- Please review the clinic rules, be compliant, and keep a copy of them with your records.
- Inform of any address, telephone number(s), and income or insurance changes.
- 24 hours in advance notice if unable to keep appointment. Failure to keep the appointment or give notice 24 hours in advance will result in a $10 no-show fee that will be billed.
- Arriving late for an appointment will result in being rescheduled for the next available time.
- Patients that fail to keep or cancel their appointments three times in a 12-month period or five times for Children under the age 18 may be prevented from scheduling future appointments for a period of six months and will be seen on a same-day or walk-in basis only.
- I understand my treatment may be unsuccessful if I fail to follow the physician’s orders and referrals.
- There is no cell phone usage or any charging of cell phones in the clinic.
- HHM reserves the right to refuse services to patients that have conducted themselves in a manner that is considered inappropriate. (Uncooperative, verbally abusive, intoxicated, etc.)
Consent for Treatment and Payment
I hereby and voluntarily consent to authorize the center’s healthcare providers to provide health care services to me at the center’s service locations. The health care services may include, without limitation, routine physical and mental assessment; diagnostic and monitoring tests and procedures; examinations and medical and/or dental treatment; routine laboratory procedures and tests; x-rays and other imaging studies; administration of medications; and procedures and treatments prescribed by the center’s healthcare providers. The health care services also may include counseling necessary to receive appropriate services including family planning (as defined by federal laws and regulations).
I understand that I will be asked to sign a separate informed consent for each vaccine to be administered to me and that I will receive a “Vaccine Information Statement” (VIS) prior to receiving each vaccine.
I understand that there are certain hazards and risks connected with all forms of treatment, and my consent is given knowing this.
I understand that this consent is valid and remains in effect as long as I am a patient of the center, until I withdraw my consent, or until the center changes its services and asks me to complete a new consent form.
I understand that payment for medical service is due on the day of the visit. Payment may be made by cash or credit card. Insurance/Financial arrangements should be made with the center prior to any service.
- I certify that I have read and fully understand the foregoing consent and that the facts indicated are true.
- I realize that although every effort will be made to keep all risks and side effects to a minimum, risks, side effects, and complications can be unpredictable both in nature and severity.
- I understand that midlevel providers (Physician Assistants, Family Nurse Practitioners and Trained Medical Assistants) may be involved in my treatment and I consent thereto.
- I understand that I may be asked to sign a separate informed consent form for certain Treatment(s).
- I hereby voluntarily give my consent to Treatment to the Center.
- I authorize the center to release any information acquired in the course of my treatment to my insurance company (s), another physician or medical facility (s). I hereby agree that I am responsible for said fee (s).
Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.
- I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
- I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.
- I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
- If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
- I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.
- I may revoke my right at any time by contacting Healing Hands Ministries at (214) 221-0855.
- I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.
- I understand that my health care information may be shared with other individuals for scheduling purposes.
- I understand that this document will become a part of my medical record.
HIPAA Authorization Release Form
STATEMENT OF INTENT
It is my understanding that Congress passed a law entitled the Health Insurance Portability and Accountability Act (“HIPAA”) that limits disclosure of my protected medical information. This authorization is being signed because it is crucial that my medical providers readily give my protected medical information to the persons designated in this authorization in order to allow me the advantage of being able to discuss and obtain advice from my family and/or friends.
Therefore, pursuant to 45 CFR 164.501(a)(1)(iv) a covered entity (being a health care provider as defined by HIPAA) is permitted to disclose protected health information pursuant to and in compliance with this valid authorization under 45 CFR Sec. 164.508.
I, ______________________________________, an individual, hereby authorize all covered entities as defined in HIPAA, including but not limited to a doctor, (including but not limited to a physician, podiatrist, chiropractor, or osteopath,) psychiatrist, psychologist, dentist, therapist, nurse, hospitals, clinics, pharmacy, laboratory, ambulance service, assisted living facility, residential care facility, bed and board facility, nursing home, medical insurance company or any other health care provider or affiliate, to disclose the following information:
All health care information, reports and/or records concerning my medical history, condition, diagnosis, testing, prognosis, treatment, billing information and identity of health care providers, whether past, present or future and any other information which is in any way related to my healthcare. Additionally, this disclosure shall include the ability to ask questions and discuss this protected medical information with the person or entity who has possession of the protected medical information even if I am fully competent to ask questions and discuss this matter at the time. It is my intention to give a full authorization to ANY protected medical information to the persons named in this authorization.
By checking above, I authorize the release of information including the diagnosis, records, examination rendered to me and claims information. This information may be released to: ** Read this to its entirety**
This authorization shall terminate on the first to occur of: (1) two years following my death or (2) upon my written revocation actually received by the covered entity. Proof of receipt of my written revocation may be by certified mail, registered mail, facsimile, or any other receipt evidencing actual receipt by the covered entity. This revocation shall be effective upon the actual receipt of the notice by the covered entity except to the extent that the covered entity has taken action in reliance on it. This authorization is not affected by my subsequent disability or incapacity.
By signing this Authorization, I acknowledge that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the person or persons whose name(s) is/are written above, and the information once disclosed will no longer be protected by the rules created in HIPAA. No covered entity shall require my authorized persons to indemnify the covered entity or agree to perform any act in order for the covered entity to comply with this authorization.
INSTRUCTIONS TO MY AUTHORIZED PERSONS
My authorized persons shall have the right to bring a legal action in any applicable form against any covered entity that refuses to recognize and accept this authorization for the purposes I have expressed. Additionally, my authorized persons are authorized to sign any documents that the authorized persons deem appropriate to obtain the protected medical information.
A copy or facsimile of this original authorization shall be accepted as though it were an original document. WAIVER AND RELEASE I hereby release any covered entity that acts in reliance on this authorization from any liability that may accrue from releasing my protected medical information and for any actions taken by my authorized persons.