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NORTHEAST EAST OHIO NEIGHBORHOOD HEALTH SERVICES, INC. REGISTRATION FORM (Please Print) PATIENT INFORMATION Middle: Previous last name: Patient's last name : First: Social Security: Birth date: Sex: I i OM OF Street address: Oty: State: ZIP Code: Race : 0 American Indian 0 Asian O Black/African American O Caucasian O Hispanic/Latino O Pacific Islander Language: Contact preference: 0 Cell Only O Don't call home O Don't call work O Don't leave message 0 Home only O O.K. to leave message O Work only O Other Marital status: D Single O Married O Divorced O Separated D Widowed O Life Partner O Other Home Phone No.: Alternate Phone No. : ( Veteran : 0 Y O N INSURANCE INFORMATION Is this patient covered by insurance? 0 Yes O No I Birth date: Person responsible for bill : I Address (if different): Home phone no.: ( ) Is this person a patient here? □ Yes 0 No Please indicate PRIMARY insurance: I Please indicate SECONDARY insurance: Plan l.D. No.: I Plan I.D. No.: Co-payment: Deductible: $ $ Patient's relationship to subscr:iber: I O Self IOSpouse I O Child I O Other I Family Size: I Annual Income: I I I Family Members Names: J Date ofBirth : Social Security No.: l Insurance Card No.: {if applicable) I I ' I I I i I IN CASE OF EMERGENCY ' Name of local friend or relative : Rel<!tionship to patient: 1 Home phone no.: Work phone no.: ' ( ) ( ) --- - Address : How did you hear about our services? - ---r-=- 0 Family O Friend O Newspaper O TV 0 Rad io 0 Health Fair O Other NORTHEAST OHIO NEIGHBORHOOD HEALTH SERVICES, INC. CONSENT/RELEASE FORM I hereby consent to such medical, dental, surgical treatment and diagnostic procedure as the physicians or dentists of Northeast Ohio Neighborhood Health Services, Inc. may prescribe for the patient noted below. I hereby authorize Northeast Ohio Neighborhood Health Services , Inc. to release any appropriate medical or dental information to any hospital to which the patient noted below may need to be admitted , or to a professional consultant selected by physicians and dentists of Northeast Ohio Neighborhood Health Services. Inc. Por la presente, doy mi consentim iento para el tratamiento med ico, dental, qu irurg ico y/o de diagn6stico que los medicos o dentistas de Northeast Oh io Neighborhood Health Services, Inc. recomienden para el paciente que se ind ica a continuaci6n. Por la presente autorizo a Northeast Ohio Neighborhood Health Services, Inc. a comun icar cualqu ier informaci6n medica 6 dental apropiada a cualqu ier hospital en el que el paciente deba ser admitido para tratamiento, segun se ind ica a continuaci6n, 6, a un asesor profesional seleccionado por med icos y dentistas de Northeast Oh io Neighborhood Health Services. EMERGENCY CONTACT In Case of Emergency Notify: ______________________ Relationship: -------------Home Phone: ------------- Address: ---------------City, State and Zip: Date /Fecha Patient's Name (Please Print) Nombre Del Paciente (Letra de molde por favor) Medical Record Number/ Numero de record medico Patient's Signature / Firma Del Paciente Relationship to Patient I In case of minor, parent or legal guardian's Relacion Con El Paciente signature Si el paciente es menor de edad, se requiere la firma del padre/madre o guardian legal. 12/1 8 2019 SITE : Hough Norwood Superior Collinwood Southeast East Cleveland Miles-Broadway Dental Van Eastslde Market Magnolia Clubhouse Other ________ Print Patient Name & DOB: _____________________Med Record# ________ PATIENT ACKNOWLEDGEMENT STATEMENT 0 I certify that the information provided below is accurate and complete to the best of my knowledge and in the event of a change in income or insurance coverage ; I will contact/notify the facility. I understand that I may apply for third-party payers I may be eligible for to assist in payment of the services I receive and/I may apply for NEON's sliding fee scale discount program. I understand that I will be financially responsible for all or a portion of my care that Is not covered by Insurance or discount program and that I will be asked to submit payment at the time of service. I authorize the release of any information necessary to establish my family's eligibility for discounted services. I give my consent to release my information to Pharmaceutical Companies for auditing purposes only for any Medication Assistance Programs of which I may enroll. Patient Signature _________________________ Date ________ Declination Stat ement (for Patient's Who Do Not Want to Comply with Sliding Scale Requirements) 0 Because you do not wish to apply or comply with the requirements to apply for our sliding fee scale discount, you are choosing to be a full-pay patient. This means that you will pay the current office visit rate at time of service ($106.00) and you will be responsible for any and all balances due after the provider's enter the charges for your visit. You will also be responsible for any lab and/or x-ray charges or other medical and ancillary services provided as part of your visit. These may be charges from NEON or an outside agency. Pharmacy services will not be discounted and payment in full is due at time o~ rvicf ~~ Patient Signature J ,.2., Date ________ FOR INSURANCE PATIENTS WHO DO NOT WISH TO PROJ IDE-INCOME DOCUMENTATION Insurance Patient (For Patients who have Insurance and do not want to comply w~h Sliding Fee Scal~ tation Requirements) ·, ~ □ 1 certify that , do not wish to supply documentation to apply f d'ri.fd~~Jnm6i:_t; eq ~H~dule and intend to utilize my insurance for payment of the services rendered . Th is means I will be respo nsibi e f}r~Ji'c~a~~es that are not covered by my insurance, to include med ical, dental, laboratory, rad iology or other services. I will self-attest to my annual income for informational purposes only, but will not provide other documentation. I understand that this information is not to be used to determine eligibility for the NEON Sliding Fee Discount Schedule. Patient Signature __________________________ Current Annual Income: $__________ _ Insurance Provider: _____________ Policy, Group# ______________ □ 1 certify that I wish to apply for NEON's discount sliding fee schedule and will attest that the information and documentation submitted is accurate and complete to the best of my knowledge. I have in no way provided false information about myself or others seeking care from Northeast Ohio Neighborhood Health Services (NEON) and understand that any false statements may revoke my acceptance in the NEON sliding fee program or from receiving care at NEON . I/my account will be responsible for all charges provided at the full charge rates and possible persecution under laws of perjury. Patient Signature __________________________ Date ________ (Office Use ONLY) PLEASE REFER TO THE CURRENT NEON SLIDI NG FEE DISCOU NT SUDE SCHEDULE NEON Employee Certification Statement I cert ify that I as ked the appl icant/recipient about al l th e sou rce s of hou se hold incom e. I have reviewed all documentatio n an d have documented such information in NEON 's practice man agem ent system. Th e info rmation reported on this fo rm was provided solely by the applicant/rec ipie nt and re flects th e income the appl icant re porte d to me. Employ ee Sig nature ______ _ ______ ____ ___ _ _ _ _ Date _______ _ GRO SS INCOME ·-------FAMILY SI ZE ______ PATIENT STATU S _ ____ _ _ The data gathered on this form will only be used to get information about you and your family so that we can better meet you medical, dental and behavioral needs. This information will not be used to withhold or deny services to you. 1. Are you covered under Medicaid , Medicare and/or any other insurance? Yes No 2. If you have private insurance, what is your annual deductible, per family member? $____ _ 3. Have you or your dependents ever applied for or been denied for Medicaid or Medicare? Yes No 4. Would you like to apply or re-apply for Medicaid today? Yes No 5. Are you unemployed? Yes No 6. Are you too sick to work or are you disabled? Yes No Please include yourself, your spouse/partner and all dependents living in the home below: NAME DATE OF BIRTH RELATIONSHIP to INSURANCE OR Head of Household MEDICAID? HEAD OF HOUSEHOLD YES or NO YES or NO YES or NO YES or NO YES or NO YES or NO □ 1. Copy ofTwo (2) recent pay stubs □ Monthly □ Bi -monthly □ B i- weekly □ Weekly □ Daily □ Other (Specify) ________ al n:IIIZJCI □ 2. Copy of most recent W-2 Form 1 c:.. :=l ~ ~ lll[t .E1 □ 3. Copy of most recent Federal Tax Return '\lf'lDT4FAST OHIO NFl~HRORHOf' f) □ 4. Copy of 1099/1098 Social Security, Pension, Disability, or Unemployment Income i ~, □ 5. Self-employment information □ 6. Other Document (Please Specify) _______-,,--_....._ ___ -=;;__--- :-:------ □ 7. Student Financial Aid Letter □ 8. Termination/Lay-Off Letter from Employer or Unemployment Denial Letter □ 9. Letter of Support (No Income) □ 10. Other Document (Please Specify) ________________ COMPLETE BELOW IF YOU HAVE NO WAY TO DOCUMENT INCOME Please complete the information below only if you have no other way to document your income. o I get paid in cash. o I do not get pay check/stubs. o I receive assistance from a family member. (Complete letter of support) o I work odd jobs. o I cannot get a letter from my employer. Explain why; My income is$ _____□ Monthly □ Bi -monthly □ Bi-weekly □ Weekly □ Daily □ Other ___ .

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