Preferred Language - Idioma preferido
English- Ingles
Spanish - Espanol
What is the child's name? First and last
* must provide value
What is the child's date of birth? (mm/dd/yyyy)
* must provide value
M-D-Y
What is the child's Social Security Number? (optional)
What is the child's sex assigned at birth?
* must provide value
Male
Female
Intersex
Prefer not to say
We will ask for pronouns later
Please enter the FIRST and LAST name of the parent/legal guardian
* must provide value
Are you the legal guardian for this child?
* must provide value
Yes
No
What is your relationship to the child?
* must provide value
Parent or Legal Guardian
Step Parent
Foster Parent
Case Worker / Staff Member
Grandparent
Self (I am the patient)
Sibling / Brother / Sister
Aunt or Uncle
Other
What organization do you work for?
What foster care agency are you working with?
What are YOUR preferred pronouns
Is there another legal guardian for this child?
* must provide value
Yes
No
What is the full name of the legal guardian? (first and last)
* must provide value
How is this legal guardian related to the child?
* must provide value
Parent or Legal Guardian Step Parent Foster Parent Case Worker / Staff Member Grandparent Self (I am the patient) Sibling / Brother / Sister Aunt or Uncle Other
Which foster agency is supporting this child?
Which organization works with this child?
What pronouns does this person use?
What is your relationship to the child?
* must provide value
Parent or Legal Guardian Step Parent Foster Parent Case Worker / Staff Member Grandparent Self (I am the patient) Sibling / Brother / Sister Aunt or Uncle Other
What are your preferred pronouns?
She/her He/him They/them Unsure Other
Please write your relationship
* must provide value
What foster agency are you with?
What organization do you work with?
What is the full name of the parent or legal guardian for the child? (if you know it)
How is the legal guardian related to the child?
Parent or Legal Guardian Step Parent Foster Parent Case Worker / Staff Member Grandparent Self (I am the patient) Sibling / Brother / Sister Aunt or Uncle Other
What foster care agency is working with this case?
Please explain the relationship
What is the legal guardian's pronouns?
She/her He/him They/them Unsure Other
Is there another legal guardian for this child?
Yes
No
What is the full name of the second legal guardian?
How is this legal guardian related to the child?
Parent or Legal Guardian Step Parent Foster Parent Case Worker / Staff Member Grandparent Self (I am the patient) Sibling / Brother / Sister Aunt or Uncle Other
Which foster agency is supporting this case?
Which organization does this person work with?
Describe the relationship
* must provide value
What pronouns does this person use?
She/her He/him They/them Unsure Other
Does the child have a PREFERRED NAME or nickname?
Yes
No
What is the child's preferred name or nickname?
What pronouns does the CHILD use?
Please write what pronouns the child uses
What is the child's gender identity?
What is the patient's ethnicity?
* must provide value
Not Hispanic or Latino
Hispanic or Latino
What is the child's Hispanic or Latino ethnicity? Check all that apply
* must provide value
Please describe the child's Hispanic/Latino ethnicity
* must provide value
What is the child's race? Check ALL that apply
* must provide value
What is the child's race? Check all that apply
* must provide value
What is your primary address?
* must provide value
street, city, state, zip code
What is your email address?
What is the BEST phone number to contact the PARENT or GUARDIAN?
* must provide value
What type of phone is this?
Cell
Home
Work
Is there a BACK UP phone number to reach the PARENT or GUARDIAN?
Please provide additional number here
What is the FULL NAME of the child's EMERGENCY CONTACT? (someone other than yourself)
What is the BEST phone number to reach the EMERGENCY CONTACT?
How is the emergency contact related to the child?
Parent or Legal Guardian Step Parent Foster Parent Case Worker / Staff Member Grandparent Self (I am the patient) Sibling / Brother / Sister Aunt or Uncle Other
Is there ANYONE ELSE who you allow to bring your child to appointments (This person will have access to your child's medical records)?
Yes
No
What is the name of this person?
* must provide value
How is this person related to the child?
Parent or Legal Guardian Step Parent Foster Parent Case Worker / Staff Member Grandparent Self (I am the patient) Sibling / Brother / Sister Aunt or Uncle Other
What agency does this person work with?
What is the BEST phone number for this person?
We are funded by the federal government and required to ask information about your finances. Please answer truthfully. We apologize for any discomfort.
How many people live in your household?
* must provide value
What is your household income per month?
* must provide value
What is your household's source(s) of income? (select all that apply)
Do you have proof of income with you today?
Yes
No
Why do you not have proof of income?
Forgot to bring Lost or do not have Income is zero Refuse to Bring Other
Is the household size and income information you provided true and correct to the best of your knowledge?
YES. The household information I have provided is true and correct. I understand that this information is used to determine eligibility for SLIDING FEE DISCOUNT programs and that it is illegal to intentionally misrepresent this information
NO. I do not wish to provide household size / income information or to affirm that household information is true or correct. I understand that I will be ineligible for any SLIDING FEE DISCOUNT PROGRAMS
Does this child have health insurance?
* must provide value
Yes
No
What is the insurance plan? (optional)
What is the insurance plan number? (optional)
Was your child born in the United States?
Yes
No
Good news! Your child is eligible for health insurance. We can help you apply.
Do you currently have one of the following documents or statuses?
* must provide value
United States Citizenship Green Card or Unexpired Visa Asylum or Refugee Status None of the above
Good News! Your child is eligible for health insurance! We can help you apply.
Good News! Your child is eligible for health insurance! We can help you apply.
Good News! Your child is eligible for health insurance! We can help you apply.
Have you applied for asylum?
* must provide value
Yes
No
Good news! Your child will be eligible for health insurance after you receive your work visa.
Are you planning on applying for asylum?
* must provide value
Yes
No
Good News, your child will be eligible for health insurance 6 months after you apply for asylum status.
Unfortunately your child is not eligible for health insurance at this time, but we can still see you!
¿Cómo se llama su niño/niña?
* must provide value
¿Cuál es la fecha de nacimiento de su hijo? (mm/dd/yyyy)
* must provide value
M-D-Y
Sexo del paciente asignado al nacer:
* must provide value
Femenino
Masculino
Intersexual
Desconocido/Otro
¿Cuál es el número de seguro social del niño? (Opcional)
Cuál es SU nombre y apellido? (Ponga el nombre SUYO, no del nino)
* must provide value
¿Eres la madre, el padre o el guardian legal de este niño?
Sí, soy la madre, el padre o el guardian legal de este niño. No, no soy la madre, el padre o el guardian legal de este niño.
¿Cuál es tu relación con la paciente?
Madre, padre, o tutor legal
Madrasta o Padrasto
Padre o Madre Adoptivo
Trabajador de caso or trabajador social
Abuelo o Abuela
Yo soy el paciente
Tio o Tia
Hermano o Hermana
Otro
Cual agencia esta trabajando con este niño?
Cual agencia esta trabajando con este niño?
Él Ella Ellos/Ellas No se Otro
Hay otro guardian legal (madre o padre) para este paciente?
Si No
Cual es el nombre del otro guardian legal del paciente?
Cómo se relaciona esta persona con el paciente?
Madre, padre, o tutor legal Madrasta o Padrasto Padre o Madre Adoptivo Trabajador de caso or trabajador social Abuelo o Abuela Yo soy el paciente Tio o Tia Hermano o Hermana Otro
Cual agencia esta trabajando con este nino?
Cual agencia esta trabajando con este nino?
Cuales pronombres use esta persona?
Él Ella Ellos/Ellas No se Otro
Cual es su relacion con el paciente?
* must provide value
Madre, padre, o tutor legal Madrasta o Padrasto Padre o Madre Adoptivo Trabajador de caso or trabajador social Abuelo o Abuela Yo soy el paciente Tio o Tia Hermano o Hermana Otro
Cual agencia esta trabajando con este nino?
Cual agencia esta trabajando con este nino?
Escribe su relacion
* must provide value
Cuales pronombres use usted?
Él Ella Ellos/Ellas No se Otro
Cual es el nombre del guardian legal (NOMBRE COMPLETO)
Cómo se relaciona esta persona con el paciente?
Madre, padre, o tutor legal Madrasta o Padrasto Padre o Madre Adoptivo Trabajador de caso or trabajador social Abuelo o Abuela Yo soy el paciente Tio o Tia Hermano o Hermana Otro
Cual agencia esta trabajando con este nino?
Cual agencia esta trabajando con este nino?
Describe la relación
* must provide value
Hay otro guardian legal del paciente?
Si No
Cual es el nombre del otro guardian legal del paciente?
Cómo se relaciona esta persona con el paciente?
* must provide value
Madre, padre, o tutor legal Madrasta o Padrasto Padre o Madre Adoptivo Trabajador de caso or trabajador social Abuelo o Abuela Yo soy el paciente Tio o Tia Hermano o Hermana Otro
Cual agencia esta trabajando con este nino?
Cual agencia esta trabajando con este nino?
Cuales pronombres use esta persona?
Él Ella Ellos/Ellas No se Otro
Tiene el paciente un Nombre preferido?
yes no
Cual es el NOMBRE PREFERIDO del paciente?
* must provide value
Cual pronombres usa su HIJO/HIJA?
Femenino
Masculino
Transexual FTM (de mujer a hombre)
Transexual MTF (de hombre a mujer)
Género no binario
Prefiero no decirlo
Otra identidad de género
Origen étnico del paciente
* must provide value
Ni hispano ni latino
Hispano o latino
Marque TODAS las opciones que correspondan (Hispano o latino)
Raza del paciente: (marque TODAS las opciones que correspondan)
* must provide value
Cual es el MEJOR numero de telefono para comunicarse con el padre, madre o guardian?
* must provide value
Que tipo de teléfono es este?
Celular Telefono de la casa Telefono del trabajo
¿Cuál es su DIRECCIÓN PRINCIPAL?
* must provide value
Calle/Ciudad/Estado/Código postal
Cuál es su dirección de correo electrónico?
Por favor proporcione un número de teléfono de respaldo
Cual es el NOMBRE del contacto de EMERGENCIA
* must provide value
Cual es el MEJOR número de teléfono del contacto de EMERGENCIA
* must provide value
Cual es la relación entre su CONTACTO DE EMERGENCIA y el paciente?
Madre, padre, o tutor legal Madrasta o Padrasto Padre o Madre Adoptivo Trabajador de caso or trabajador social Abuelo o Abuela Yo soy el paciente Tio o Tia Hermano o Hermana Otro
Hay alguien mas permitido para llevar el paciente a las citas? (Esta persona tendra acceso a los registros medico del nino)
Si No
Cual es el NOMBRE de esta persona?
* must provide value
Cual es el NUMERO DE TELEFONO de esta persona?
* must provide value
Cual es la relacion de esta persona con el paciente?
* must provide value
Madre, padre, o tutor legal
Madrasta o Padrasto
Padre o Madre Adoptivo
Trabajador de caso or trabajador social
Abuelo o Abuela
Yo soy el paciente
Tio o Tia
Hermano o Hermana
Otro
Debido a que estamos financiados por el gobierno, debemos solicitar informacion financiera. Nos disculpamos por cualquier inconveniente
Cuantas personas viven en su casa?
* must provide value
Cual es la cantidad de sus ingresos familiares por mes?
* must provide value
¿Cuál es la fuente de ingresos de su hogar? Seleccione todas las que correspondan
Trajo un comprobante de ingresos hoy?
Si No
Por favor explique por qué no tiene comprobante de ingresos
Olvido traierlo Lo perdio / No tiene El ingreso es CERO Se nego Otro
La informacion sobre el tamano del hogar y los ingresos que ha proporcionado es verdadera y correcta segun su conocimiento?
Si No
Su hijo tiene seguro de salud?
* must provide value
Si No
¿Cuál es el plan de seguro y el número? (opcional)
Nació su hijo en los estados unidos?
* must provide value
Si No
BUENAS NOTICIAS! SU HIJO ES ELEGIBLE PARA EL SEGURO DE SALUD. PODEMOS AYUDARTE A APLICAR
Tiene uno de los siguientes documentos o estado? (marque cuál)
Ciudadania de los Estados Unidos Tarjeta verde or Visa No Vencida Asilo o condicion de refugiado Ninguno de los anteriores
BUENAS NOTICIAS! SU HIJO ES ELEGIBLE PARA EL SEGURO DE SALUD. PODEMOS AYUDARTE A APLICAR
BUENAS NOTICIAS! SU HIJO ES ELEGIBLE PARA EL SEGURO DE SALUD. PODEMOS AYUDARTE A APLICAR
BUENAS NOTICIAS! SU HIJO ES ELEGIBLE PARA EL SEGURO DE SALUD. PODEMOS AYUDARTE A APLICAR
Si No
BUENAS NOTICIAS! SU HIJO SERA ELEGIBLE PARA SEGURO DE SALUD CUANDO RECIBA SU VISA DE TRABAJO. PODEMOS AYUDARTE APLICAR
Si No
BUENAS NOTICIAS! SU HIJO SERA ELIGIBLE PARA SEGURO DE SALUD 6 MESES DUSPUES DE SOLICITAR EL ESTADO DE ASILO
DESAFORTUNADAMENTE, AHORA MISMO SU HIJO NO ES ELEGIBLE PARA SEGUDO DE SALUD. PERO TODAVIA PODEMOS VERLO!
Can we EMAIL YOU messages that may contain protected health information at the email addresses you provide to us?
* must provide value
Yes
No
Can we leave VOICEMAIL messages at the phone numbers you provide to us?
* must provide value
Yes
No
Can we TEXT you at the number you provided to us?
* must provide value
Yes
No
Can we send POSTAL MAIL that includes protected health information to the home address you provided?
Yes
No
Would you like to receive AUTOMATED REMINDERS about the following (select all that apply):
Podemos enviar CORREO ELECTRONICO con su information de salud protegida a la direccion de correo electronico que nos proporciona?
Si No
Podemos dejar MENSAJES DE VOZ en el número de teléfono que nos proporciona?
Si No
Podemos enviarle MENSAJES DE TEXTO al numero de telefono que nos proporciona?
Si No
Podemos enviar RECORDATORIOS AUTOMATICOS? (Marque todo lo que importa)
Podemos enviar CORREO POSTAL, incluido informacion de salud protegida, a la direccion que nos proporciona?
Si No
Has the child's legal guardian changed since the last visit?
* must provide value
yes no
Please stop and give this computer to the Front Desk. They will need to register the child as a NEW patient
Ha cambiado el guardian legal del nino desde la ultima cita con nosotros?
* must provide value
Si No
Por favor pare y dar este computadora a la recepcion para que puedan registrarlo como PACIENTE NUEVO
The following are consents for the patient.
______
______
Philadelphia FIGHT Community Health Centers
CONSENT FOR TREATMENT AND RELEASE OF HEALTH INFORMATION
Rev.01/2020 BOD Approved 01/22/2020
FOR LEGALLY AUTHORIZED REPRESENTATIVES WHO ARE COMPLETING THIS CONSENT ON BEHALF OF A PATIENT:
Name of Legally Authorized Representative:
______
Legally Authorized Representative's Relationship to Patient:
______
CONSENT FOR TREATMENT: I, as the patient or patient's legally authorized representative, hereby consent to the
performance of such diagnostic procedures and/or medical treatment, including the administration of blood products, as
deemed necessary or advisable by the physician/s and/or health care provider/s at the Jonathan Lax Treatment Center, John
Bell Health Center, Y-HEP Health Center, Pediatric and Adolescent Health Center, Clinica Bienestar, Broad Street Ministry
Health Center and /or Philadelphia FIGHT Dental Services (all entities referred to collectively as the Philadelphia FIGHT
Community Health Centers). I hereby consent to the performance of all nursing and technical procedures and tests as directed
by these physician/s and/or health care provider/s.
2. COMPLIANCE WITH RULES AND REGULATIONS: In consideration of treatment, I agree to abide by the rules of the Philadelphia
FIGHT Community Health Centers.
3. ASSIGNMENT OF BENEFITS: As the patient or patient's legally authorized representative, I hereby make the assignment of
benefits as set forth below:
MEDICARE AND/OR MEDICAID: I authorize any holder of medical, dental or other protected health information about me, the
patient, or about the patient that I am legally authorized to represent, to release this information to Medicare and/or
Medicaid. This information is disclosed for the purpose of billing and obtaining payment for care and for obtaining
authorization for necessary treatment. I hereby authorize direct payment to Philadelphia FIGHT for medical, dental and/or
surgical benefits from Medicare and/or Medicaid. I also permit a copy of this authorization to be used in place of the original.
GENERAL AUTHORIZATION: I authorize any holder of medical, dental or other protected health information about me, the
patient, or about the patient that I am legally authorized to represent, to release this information to any another medical
practice or medical provider involved in my, or the patient's care. This information is disclosed for the purpose of billing and
obtaining payment for care, for obtaining authorization for necessary treatment and for coordination of care.
I authorize any holder of medical and/or dental information or other protected health information about me, the patient, or
about the patient that I am legally authorized represent, to release this information to my or the patient's insurance company,
the intermediaries or carriers, and/or to my or the patient's attorney. This information is disclosed for the purpose of billing
and obtaining payment for care. I hereby authorize direct payment to Philadelphia FIGHT for medical, dental and/or surgical
benefits from my or the patient's private insurance company or other health plans. I also permit a copy of this authorization to
be used in place of the original.
4. IMMUNIZATION INFORMATION SYSTEM: I authorize the physician/s and/or health care provider/s and/or public health
agency to collect and enter my immunization records, or the immunization records of the patient I am legally authorized to
represent, into the Department of Health and Human Services' Immunization Information System (IIS). The IIS is a confidential,
computer system that contains immunization records. I understand that information in the registry may be released to a
public health agency as well as all my or the patient's health care providers to assist in medical care and treatment. In
addition, information may be released to other facilities at which I, or the patient, am enrolled as a patient to comply with
state immunization requirements.
5. PHARMACY BENEFITS STATEMENT: A "Pharmacy Benefits Statement" (PBM) is a statement that shows all medications that
have been processed through an insurance company for any period of time regardless of the prescriber. I authorize
Philadelphia FIGHT to view my PBM, or the PBM of the patient I am legally authorized to represent, download my or the
patient's PBM, and make it an ongoing part of my or the patient's electronic medical records.
CLINICAL TRIALS ELIGIBILITY SCREENING: Philadelphia FIGHT conducts clinical trials of new and potential treatments for
different disease states. Additionally, FIGHT studies various factors related to these disease states such as prevention of
diseases and treatment adherence. The purpose of this research is the overall goal of improving health outcomes. I authorize
Philadelphia FIGHT health care provider/s and/or Philadelphia FIGHT research staff to review my medical/dental chart, or the
medical/dental chart of the patient I am legally authorized to represent, and contact me if a clinical trial is appropriate for or
the patient. This is not authorization to enroll myself or the patient in any trial and I understand that I or the patient is not
obligated to participate in any research.
7. FINANCIAL ASSISTANCE/SLIDING FEE PROGRAM: I understand that if I, as the patient, am uninsured or underinsured, or the
patient I legally represent is uninsured or underinsured, financial assistance may be available. If I need assistance I can contact
the Health Centers' benefits coordinators or medical case managers for further information about financial assistance for
uninsured or underinsured patients. I understand that I will need to provide timely information to verify my or the patient's
eligibility for sliding fee/financial assistance. I understand that my or the patient's application for financial assistance/sliding
fee expires one year from the date of the original application and to continue receiving financial support I must reapply if the
application has expired.
8. HEALTH INFORMATION EXCHANGE: I understand that Philadelphia FIGHT participates in certain health information exchanges
with other hospitals and health centers, including the "HealthShare Exchange of Southeastern Pennsylvania, Inc., ("HSX"). I
have been informed that my health information, including limited information relating to mental health and substance abuse
services that I may receive at Philadelphia FIGHT, will be shared with these exchanges. Notes from my psychiatrist, mental
health therapist or addiction counselor will not be shared, but diagnosis codes and a history of my visits will be shared. I
understand that information about me is being shared with providers and public health officials outside of the health center
for treatment purposes, in order to better coordinate my care and to assist providers and public health officials in making more
informed decisions. I have been advised by Philadelphia FIGHT that I have the right to "opt-out" of health information
exchanges at any time. I understand that I can request a copy of the "opt-out" form from Philadelphia FIGHT and direct
Philadelphia FIGHT to disable access to my health information, except to the extent that disclosure of such information is
permitted or mandated by law.
REQUIREMENTS OF OUR FUNDERS: I understand and agree that Philadelphia FIGHT may use and disclose medical/dental
information about me, the patient, or about the patient that I am legally authorized to represent, to comply with the
requirements of Federal, state, and local government funders.
BY MY SIGNATURE, I CERTIFY THAT I AM THE PATIENT OR LEGALLY AUTHORIZED TO ACT FOR THE PATIENT, HAVE READ
PARAGRAPHS 1-9 OF THIS DOCUMENT, UNDERSTAND ITS CONTENT, AND AGREE TO ITS TERMS. I UNDERSTAND THIS
AUTHORIZATION WILL REMAIN IN EFFECT UNTIL REVOKED BY ME IN WRITING.
______ Printed name
Please Initial:
Acknowledgment: I acknowledge that I have been given and received a copy of the Philadelphia FIGHT Notice of Privacy Practices, Patient Bill of Rights and Responsibilities, and Grievance Procedures. I understand that
Philadelphia FIGHT reserves the right to change the terms of the Notice of Privacy Practices from time to time and that I may contact Philadelphia FIGHT at any time to obtain the most current copy of the Notice of Privacy Practices.
If I have a concern about Philadelphia FIGHT Notice of Privacy Practices, Patient Bill of Rights and Responsibilities, or Grievance
Procedures, I may contact Mimi McNichol, by phone: (215) 985-4448 ext. 223, by email: mcnichol@fight.org, or by mail: 1233 Locust
Street, 5th floor, Philadelphia, PA, 19107.
* must provide value