Updated February 2020

REGISTRATION FORM(Please Print)

PATIENT INFORMATION

Last Name: First Name: Middle Initial:

Social Security Number: Birth Date:

Sex: ☐M ☐ F

Street Address:

City State, Zip:

County:

Mailing Address: ☐Same as above

Leave a message: ☐ Home Phone Number ☐ Cell Phone Number

Email Address: Home Phone Number: Cell Phone Number: Work Phone Number:

Marital Status:☐Divorce ☐Married ☐Single ☐Separated☐Widow

Preferred Pharmacy: Homeless Status: ☐ Transitional ☐Doubling Up ☐ Homeless Shelter ☐ Other ☐Homeless ☐Seasonal ☐Migrant

Race: ☐Asian ☐ American Indian/Alaskan Native ☐Black or African American ☐White ☐ Native Hawaiian ☐Pacific Islander ☐Unreported/Refused to Report

Primary Language: ____________________________

Translator: ☐Yes ☐No

Ethnicity (choose only one): ☐Hispanic/Latino ☐Not Hispanic ☐Refused to report

Veteran Status (choose only one): ☐Yes ☐No

Employer Name :

Employer Status: ☐Full Time☐Part Time

Student: ☐Yes ☐No

Student Status: ☐Full Time ☐PartTime

Primary Care Provider (PCP) Name:

Does the patient have any problems with: ☐Vision ☐Hearing ☐Reading ☐Speaking Explain:

Parent/Guardian OR Responsible PartyName:

Address: ☐Same as above Phone Number: ( )

Parent/Guardian OR Responsible Party SSN:

Birth Date:

Relationship:

Housing (Check One): ☐Own ☐Rent ☐Public Assisted ☐Friend Other:___________________________________

MEDICAL INSURANCE INFORMATION

(Please give your insurance card to the Patient Service Representative)

Person responsible for bill: Birth date: Address (if different): Primary Phone Number: ( )

Occupation: Employer: Employer Phone Number:

Patients relationship to subscriber: ☐Self ☐Spouse ☐Child ☐Step Child ☐Other

Primary Medical Insurance: ☐Medicare ☐Medicaid☐Blue Cross BlueShield

☐Other:

Subscriber’s Name: Birth Date:

Policy #: Group #: Co-Payment: $

Name of Secondary Medical Insurance (ifapplicable):

Subscriber’s Name: Birth Date:

Policy #:Group #:

IN CASE OF EMERGENCY

Name of local friend or relative: Relationship to patient: Primary Phone Number

Signature: Date:

Updated February 2020

(Patient Name)GENERAL CONSENT FOR DIAGNOSIS AND TREATMENTUPON REGISTRATION AND FINANCIAL RESPONSIBILITY

I hereby certify that I have not knowingly withheld any information or income or other financial resources and the amounts I havedisclosed are true and correct to the best of my knowledge. The undersigned patient and/or responsible person or relative having registered at Swope Health services for the purposes ofobtaining health services, do hereby, voluntarily consent to such diagnostic and treatment services, as might be provided by or at thedirection of a physician, dentist, other health care professional or other qualified member of the staff of the Swope Health Services to meaccording to his/her judgment. I recognize that I have the right to refuse any specific diagnostic or treatment service without jeopardizing my right to receivehealth services at the Center. I recognize that I will be asked to sign a specific consent for surgical and other special procedures including general and/orextensive local anesthesia. I am aware that health services are not based on an exact science, and I acknowledge that no guarantees have been made tome as to the results of any treatment services, I hereby authorize Swope Health Services to retain, preserve and use for scientific or teaching purposes or dispose of at theirconvenience any specimen or tissue taken from my body during my treatment. I hereby authorize payment of health insurance benefits recorded on the registration form to be paid directly to Swope HealthServices for services provided. I hereby authorize the Swope Health Services to furnish such information from my medical record pertaining to any and alltreatment as requested by either health insurance plans or companies, if applicable to my case.

This form has been fully explained to me, and I certify that I understand its contents. This file is to be updated in thirty days or one yearwhich ever applies. I understand the charges for which I am responsible will reflect the balance due after credit for all appropriate discounts and allcollections received by Swope Health Services from health insurance benefits for the above named individuals.qMedicare qMedicaid qManaged Care Plans qMental Health qHomeless qOther (Specify) ___________________________I agree to pay these charges on the day that the services are provided, within 10 days of receipt of the statement from SwopeHealth Services or by some other payment arrangement agreed to by Swope Health Services Patient Relations Office, telephone816-923-5800* Knowingly concealing, failing to disclose, or providing false information with the intent to receive benefits that you are notentitled may result in prosecution, disbarment from Medicaid, Medicare and any other Government funded programs ______________________________________________________________ ________________________________Patient/Parent/Legal Guardian Signature Date

______________________________________________________________ ________________________________Witness DateI, the patient wish to authorize release of information about any claim upon its request to another organization which provides healthinsurance for me, or my State Medical assistance agency and/or to the Department of Mental Health.

______________________________________________________________ ________________________________Patient/Parent/Legal Guardian DateCONFIRMATION OF RECEIVING PATIENT BILL OF RIGHTSI have received a brochure about the services offered at Swope Health Services. Inside of which is a copy of Swope Health Services“Patient Bill of Rights.” After reading this document, I have had a chance to ask questions and I believe I understand what the Patient Billof Rights means, what I might expect from this health care facility and what is expected of me and my family member(s) as registeredpatients here.

_____________________________________________________________ _____________________ ___________________Patient/Parent/Legal Guardian Signature Date Interviewer Initial

SELF-DECLARATION OF INCOME FORM Guarantor’s account# _________________________

I, _____________________________________________________ certify that my current annual household income is$___________________ and my family size is ________________. I declare that all of my dependents are 18 years old andyounger or disabled. I understand that this self-declaration is good for 30 days only. To receive a discount on services for a 12month period, I will need to provide proof of my income by_______________________________________.

q I decline to participate in the sliding fee discount program. Guarantor Signature________________________________________________ Date___________________

Witnessed By______________________________________________________ Date____________________

Updated February 2020

UNSECURE COMMUNNICATION OF HEALTHCARE INFORMATION Patient Name: _____________________________ Date: ____________

Person Signing for Patient: ___________________ (PRINT) ___________(Relationship)

Swope Health sends sensitive health information using its secure Patient Portal. If you are not signed up for the PatientPortal, please ask to sign up.Swope Health would also like to send you information about your healthcare using unsecure communication such as textmessaging, email and telephone voicemails. This communication can be used to remind you of appointments and remindyou of important healthcare tests that you may need.

Before agreeing to unsecure electronic messages from Swope Health, please understand the following:1. There is a risk that unsecure email, text and voicemails with healthcare information can be seen or heard by others.2. Unsecure email and texts are for convenience and may NOT be used for emergency or highly sensitive information.3. Employers may have the right to access your personal email using a work email address and your personal text or

voicemail on a work telephone. 4. Swope Health is not liable or responsible for email, text or voicemail messages lost or misdirected due to technical errors

or if you provide an incorrect or incomplete email and/or phone number. 5. This authorization is voluntary, and I do not have to sign it. This authorization is not required for me/patient to receive

medical, dental and/or behavioral/mental health care at Swope Health and I can discontinue this authorization in writing atany time.

This form can be used to allow or stop unsecure electronic messages between you and Swope Health. VOICEMAIL

____ I authorize Swope Health to use unsecure voicemail to communicate with me about my medical care andtreatment, including appointment reminders, testing reminders and account status.

____ I DISCONTINUE authorization for unsecure voicemail messages from Swope Health about my healthcare.EMAIL

____ I authorize Swope Health to use unsecure email to communicate with me about my medical care and treatment,including appointment reminders, testing reminders and account status.

____ I DISCONTINUE authorization for unsecure email communication from Swope Health about my healthcare.TEXT

____ I authorize Swope Health to use unsecure text to communicate with me about my medical care and treatment,including appointment reminders, testing reminders and account status.

____ I DISCONTINUE authorization for unsecure text communication from Swope Health about my healthcare.

I AUTHORIZE Swope Health Services to send me healthcare information using the unsecure methods I have identifiedabove.

___________________________________ __________Patient/Representative Signature Date

I DISCONTINUE authorization for Swope Health Services to send me healthcare info. using the unsecure methods asidentified above.

____________________________________ __________Patient/Representative Signature Date

Updated February 2020

Swope Health Services Registration (Please Print)

Name: _______________________

DOB: ___________________

About Our Notice of Privacy Practices

We are committed to protecting your personal health information in compliance with thelaw. The attached Notice of Privacy Practices states:

· Our obligations under the law with respect to your personal health information.· How we may use and disclose the health information that we keep about you.· Your rights relating to your personal health information.· Our rights to change our Notice of Privacy Practices.· How to file a complaint if you believe your privacy rights have been violated.· The conditions that apply to uses and disclosures not described in this Notice.· The person to contact for further information about our privacy practices.

We are required by law to give you a copy of this notice and to obtain your writtenacknowledgement that you have received a copy of this notice.

Patient Acknowledgment of Receipt

I, , hereby acknowledge that I havereceived a Copy of the Notice of Privacy Practices. _____________________________________________________________________Patient’s Signature Date

_____________________________________________________________________Signature of Parent or Patient’s Representative (if applicable)

_____________________________________________________________________Description of Legal Authority to act on Behalf of Patient

Updated February 2020

SWOPE HEALTH SERVICES3801 Blue Parkway

Kansas City, MO. 64130(816)923-5800 FAX: (816) 922-7682

Authorization for Release of Protected Health InformationTo be completed by the patient or the patient’s authorized representative:

Patient’s Name Date of Birth: ___________________

Street Address__________________________________________________________

City_________________________ State_______________ Zip Code___________ Telephone ___________________________ Fax ___________________________I hereby authorize:£ Swope Health Services, OR

£ ___________________________________________________________Name of Physician or Provider______________________________________________________________Street Address______________________________________________________________City State Zip Code______________________________________________________________Telephone Fax To release my confidential health information, as described below, to: £ me

£ Swope Health Services, or£ __________________________________________________________Name_____________________________________________________________Organization Name_____________________________________________________________Street Address_____________________________________________________________City State Zip Code_____________________________________________________________Telephone Fax

£ copies by mail £ inspection£ copies by fax £ other: _________________ £ copies to be picked-up

Form#: 72003 (Rev. 10/04/2012) 1

Updated February 2020

For the following purpose(s): · If for marketing purposes, indicate whether the marketing involves direct or indirect payment to Swope

Health Services. · If requested by the patient, a statement “at the request of patient” is sufficient.

My authorization is for the use and disclosure of the following records:___ Statements of charges and payments ___ Diagnosis/treatment of medical illness and records of medical examinations___ Mental health records___ Dental records___ Evaluation and treatment records related to alcohol and/or drug abuse.___ X-rays and other images ___ AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus)information___ Other: _________________________________________________ All of the aboveMy authorization pertains to information generated on the following date(s) orin the following time period:_________________________________________________________________________________________ My authorization is given freely with the understanding that:

· I may refuse to sign this authorization.· I may revoke this authorization at any time, except where information has already been released in

reliance on my authorization, provided that my revocation is in writing.· Swope Health Services may not condition my treatment on my provision of this authorization.· This authorization is valid for a thirty (30) day period from the date it is signed or sooner if so specified

by me, as indicated below.· A photocopy or fax of this authorization is as valid as the original.· Swope Health Services, its directors, officers, employees, agents and volunteers are hereby released

from any legal responsibility or liability for disclosure of the above information to the extent indicatedand authorized herein.

· I will be given a copy of this signed authorization if the authorization is at the request of Swope HealthServices.This authorization will expire on: ________________________________ Patient’s Signature Date Signature of Parent or Personal Representative Date Name of Parent or Personal Representative (please print) Description of Legal Authority to Act on Behalf of Patient Witness Signature Date

Form#: 72003 (Rev. 10/04/2012) 2

Updated February 2020

Sliding Fee Discount Eligibility Form

It may be necessary to ask some personal questions in order to determine eligibility for a discount on medical,dental or pharmaceutical charges. This information is private and confidential and will be kept on file at SwopeHealth Services. Income verification is determined once a year and requires proof of income and Proof ofaddress documents to be return to Swope Health Services. (Family size and annual gross household income willbe used to calculate discount and level of payment.)

List other Household Members 19 years of age and older that live with you.

Name DOB Relationship

1

2

3

4

5

6

List other Household Members 18 years of age and younger or disabled that live withyou.

Name DOB Relationship

1

2

3

4

5

6

7

8

9

Updated February 2020

Do you have any wage income from any of the following household members:

Sources Hourly Rate Hours Worked Bi-weeklyIncome

Hoursworked

You

Your Spouse or Significant Other

Other persons (Please List)

Do you have any income from any of the following sources and if so, how much per month?

Sources You Your Spouse Your ChildrenOther

PersonsTotal

Sources

Social Security

Public Assistance

Retirement Pension

Rental Income

Interest Income

Child Support - Alimony

Other (Specify)

The sliding fee discount program has been explained to me, and I acknowledge that deliberately providing false or incompleteinformation in regard to determining the level of sliding fee scale discount can disqualify me or family members from beingeligible for this program.

Guarantor Signature______________________________________________________ Date_____________________

Updated February 2020

Sliding Fee Discount- Revised Oct 2016

If you are not insured, fees for clinic services are based on your income and family size and may be reduced if you live on a

limited income according to state and federal guidelines. To qualify for discounts, you must present the following information

as applicable when you register:

Acceptable Documentation for Proof of Income (please provide proof for all family/household income): · Current Paycheck stub.

· A letter on company letterhead. Please include the following information: hourly rate, gross pay and the pay period.If your employer does not have company letterhead, we will accept a notarized letter from your Employer. Please include the following information: hourly rate, gross pay and the pay period.

· Current Unemployment Determination Letter.

· Social Security, pension, trust, SSI Disability award letter, food stamp budget summary or child support check.· Current financial aid, Pell Grants, scholarship papers.

· Current tax information.· Bank statements showing consistent payroll deposits.· W2 Forms (adjusted gross income).

· For elderly parents living with adult children or adult grandchildren, include income if adult children or adult grandchildrenclaim parents as dependents on their tax return. Otherwise, parents should be considered as independent for thepurposes of income and so do not count their adult children’s income.

· Non-cash items such as food stamps are not included in the income

Acceptable Documentation for Proof of Address:

· Current utility (electric, gas or telephone) bills.

· Driver’s license (address must match current address listed on registration).

· A current piece of mail addressed to you (within 30 days).

· Current pay check stub with your current mailing address located on the check stub.· Any government information that was mailed to you (Social Security, pension, trust, SSI Disability

Award letter, food stamp budget summary or child support check.

· Lease or mortgage agreement.· Photo or printed electronic copy of utility bills, bank statements or paycheck stubs.· Attestations from a social worker. (For homeless individuals)

PLEASE ENSURE YOU RETURN ALL THE INFORMATION AT THE SAME TIME

I understand if I do not provide the above information within thirty (30) days from today, I will be fully responsible for allservices rendered and these services will be billed at the full price until information is returned.

You may return requested information Monday through Friday from 8:00am to 4:30pm or email this Information to PSRGroupMail@swopehealth.org.

Updated July 2019

Acceptable Documentation for Identification

· Driver’s License (Includes Expired)

· Matricula Consular/ Consular Identification Card http://www.migrationpolicy.org/article/consular-id-cards-mexico-and-beyond

· Passport (Includes Expired)

· School/College Identification Card

· Guardianship Documentation

· Social Security Card

· Birth Certificate

· An Individual Taxpayer Identification Number (ITIN)- This is a tax processing number issued by the Internal RevenueService. It is a nine-digit number that always begins with the number 9 and has a range of 70-88 in the fourth andfifth digit. Effective April 12, 2011, the range was extended to include 900-70-0000 through 999-88-9999,900-90-0000 through 999-92-9999 and 900-94-0000 through 999-99-9999. IRS issues ITINs to individuals who arerequired to have a U.S. taxpayer identification number but who do not have, and are not eligible to obtain a SocialSecurity Number (SSN) from the Social Security Administration (SSA).

Who does SHS define as “Family/Household”?

· Husband, Wife and Dependent Children (any age, related biologically or adopted)

· Significant Other

· Unmarried Partners

· Mother, Father if included on the tax return

· Grandparents if included on the tax return

· Grandchildren if included on the tax return

· All members included on the tax return

Updated July 2019

STEPS TO FILE AN UNEMPLOYMENT DETERMINATION CLAIM

1. Call 816/889-3101 Missouri or 913/596-3500 Kansas

2. Press 1 to file claim

3. Enter social security number

4. Press 1

5. Select your Pin Number (This is a number you make up)

6. Press 1 for YES and 9 for NO

7. Press 1 to File by Phone

8. Follow Instructions for Address and Zip Code

9. Remain on the phone until you speak with a representative (Do not hang up)

10. Tell the representative you need the form letter showing you are either the insured or uninsured worker

The representative will mail you a Benefits Determination Letter

Updated July 2019

Consent for Care in Absence of Parent /Guardian

I, _______________________________________________ give permission for(PRINT Full Name of Parent or Guardian)

the following adults or caregivers:

_______________________________ and/or _____________________________(Print Full Name) (Print Full Name)

to accompany and consent for any medical examination or treatment for my child orchildren listed below in my absence:

________________ ______/______/_____ (Full name) (Date of Birth)

________________ ______/______/_____ (Full name) (Date of Birth)

________________ ______/______/_____ (Full name) (Date of Birth)

________________ ______/______/_____ (Full name) (Date of Birth)

I understand that it is my responsibility to inform the above mentioned adult(s) to presentwith a government issued picture identification [green card, visa, State ID, passport,driver’s license] or employee picture identification when obtaining care for my children. Furthermore, I understand that this consent expires on _____________________, andmust be renewed annually thereafter Date

_________________________________ _______________Signature of Parent or Guardian Date

_________________________________ _______________Witness Signature Date

Form# 03012 Rev: 10/04/2012

Updated July 2019

Patient Authorization and Consent (Opt-In) FormSwope Health Services participates in three Health Information Exchange networks: Missouri Health Connection (“MHC”),Lewis and Clark Information Exchange (“LACIE”), and Kansas Health Information Network (“KHIN”). These securenetworks allow doctors and other caregivers to electronically share a patient’s health records with other participatingorganizations, to improve coordinated care. Only authorized health care organizations and professionals involved in apatient’s treatment, care, quality improvement, or payment are allowed access to a patient’s records. A full list ofmembers of the health information exchange can be viewed at the MHC, LACIE, and KHIN websites. Medical recordinformation is protected under federal and state privacy laws; access, use, and disclosure of medical records will complywith the laws.

By signing this form, I understand, agree and consent to the following:1. This form is for patients who want to share their health information using the health information networks Swope

Health Services participates in. By signing this form, I agree to allow my healthcare providers to electronicallyshare my health records through Missouri Health Connection (“MHC”), Lewis and Clark Information Exchange(“LACIE”), and Kansas Health Information Network (“KHIN”).

2. I understand my records are still subject to the law, and there are penalties for anyone sharing my data in thewrong way. Using my health information for advertising, insurance or employment eligibility, is prohibited.

3. Health care providers participating in a health information exchange may copy or include my health data in theirown medical records when caring for me. Even if I later cancel my consent, providers I’ve visited who have copiedmy records are not required to remove them.

4. The health information exchange networks will keep track of who views my health records to make sure they aresecure. I can ask my doctor or each of the health information exchange networks for a list of who has looked at myrecords. If I suspect or learn that my data was shared or accessed in the wrong way, I may contact Swope HealthServices’ Compliance Department at 816-923-5800.

5. I understand and agree that Swope Health Services and other healthcare providers will be able to see all of myhealth records from both before and after today’s date. I understand this may include illnesses or injuries, testresults, medicines I am taking or have taken, and sensitive data including but not limited to:

· Alcohol or substance abuse problems · Genetic (inherited) diseases or tests · HIV/AIDS · Sexually transmitted diseases · Family planning information (including abortions) · Head and spinal cord injuries· Mental health and developmental disabilities

Updated July 2019

6. I understand that this Swope Health Services consent form will opt me into all three health information exchangenetworks. My consent will remain in effect until the day I cancel it by “Opting Out.”

7. I acknowledge that it can take up to 10 business days to process this consent formBy signing this form, I give allparticipating providers the right to share all of my health records, including sensitive data, with the healthinformation exchanges and the participating providers who have a treatment relationship with me, for purposes ofproviding care to me.

Print Full Name (First, Middle, Last, (Maiden)): ___________________________________

Date of Birth (Day, Month, Year): ______

Address (Street, City, State, Zip Code): ____________________________

Phone (xxx-xxx-xxxx): Email: rloenen@swopehealth.org

Printed Name of Legal Representative: ___ Relationship of Legal Representative: __________________

*Parental or guardian consent on behalf of the child is only valid until he or she turns 18. At that time, the child will be automatically opted out unlesshe or she chooses to consent.My or My Legal Representative’s Signature*

Date of Signature:

-----Admin Use Only below-----Participating Health Care Provider Member Organization Name:

Representative Name (print):

Representative Title: Date: Phone:

Representative Signature:

Updated July 2019

Health Information Exchange Restriction (Opt-Out) FormSwope Health Services participates in three Health Information Exchange networks: Missouri Health Connection (“MHC”),Lewis and Clark Information Exchange (“LACIE”), and Kansas Health Information Network (“KHIN”). These securenetworks allow doctors and other caregivers to electronically share a patient’s health records with other participatingorganizations, to improve coordinated care. Only authorized health care organizations and professionals involved in apatient’s treatment, care, quality improvement, or payment are allowed access to a patient’s records. A full list ofmembers of the health information exchange can be viewed at the MHC, LACIE, and KHIN websites. Medical recordinformation is protected under federal and state privacy laws; access, use, and disclosure of medical records will complywith the laws.

Please initial that you have read and understand each of the following statements:

____ I am signing this form because I do not want my health records shared through the health information exchangenetworks in which Swope Health Services participates.

____ Signing this request cancels any written consent I completed before this date, and Swope Health Services will notshare my records with any of the health information networks in which it participates.

____ I understand that I may also need to complete additional forms to opt-out of each health information exchange onthe health information exchange’s website.

____ My doctors and caregivers in other health organizations will not be able to see my electronic health recordsthrough the health information exchange network.

____ I may choose to join the health information exchange again at any time by signing a Consent Form.

Print Full Name (First, Middle Initial, Last): Ecw2_ _ Test_

Previous Names or Nicknames: _________________________________________________________________________

Date of Birth: ________________ Gender: _________________ Social Security Number: ____________________

Address: ________________________________________________________ Phone: ___________________________

Patient or Guardian Signature: ______________________________________ Date: ____________________________--------------------------------------------------------------------------------------------------------------------------------------------------------------------

To Be Completed by a Notary Public (if not completed before Swope Health Services staff member)

State of County of ______ The foregoing instrument was acknowledged beforeme, a Notary Public, on by ________________________________ (patient name), known to me to be theperson whose name is subscribed to the within instrument, & acknowledged that he/she executed the same for thepurposes therein contained. Notary’s Signature ______________________________

Instructions forSubmission:

Mail: Swope Health Services3801 Blue ParkwayKansas City, MO 64130

Notary Stamp