Date: ________________________
MRN: ________________
PRIMARY INSURANCE
Plan Name: _________________________________________________ ID Number: ________________________________
Address: ___________________________________________________ Group Number: ____________________________
Policy Holder: _______________________________________________ Effective Date: _____________________________
Policy Holder’s Social Security No.: ______________________________ Sex: £ M £ F
Policy Holder’s Date of Birth: ___________________________________ Employer: _________________________________
SECONDARY INSURANCE
Plan Name: _________________________________________________ ID Number: _______________________________
Address: ___________________________________________________ Group Number: ____________________________
Policy Holder: _______________________________________________ Effective Date: _____________________________
Policy Holder’s Social Security No.: ______________________________ Sex: £ M £ F
Policy Holder’s Date of Birth: ___________________________________ Employer: _________________________________
Payment Policy: CCHC requires payment on the day of service. This payment includes outstanding deductibles, co-payments, non-covered services, sliding
fee payments and any charges remaining after insurance has made payment on your account. Please be advised that your insurance may not cover all of
your charges and that you are responsible for any balance on your account and will be bi
lled until that balance is paid. The Sliding Fee Program is available
for
families with
low incomes. This program allows patients to get a discount on their charges. You must apply with registration staff with documentation
of total income and number of persons in the household. You must reapply for the program every year and payment must be made at time of service.
Signing of this form indicates you are aware of above policies and procedures and were advised of the sliding fee program. I hereby authorize assignment
of all insurance benefits
payable directly to CCHC.
________________________________________________________________________ __________________
Patient/Guardian Signature Date
Referrals/Option to Choose: CCHC is a primary care provider and is not equipped to provide all medical services that may be appropriate for your
medical care. In some cases, CCHC may recommend that you receive additional medical services, such as laboratory services, imaging services or
specialty care from another healthcare provider. In the event that this does occur, please be advised that you may be required to pay on the day of
service and/or be billed for any balance on your account with the referral provider.
________________________________________________________________________ __________________
Patient/Guardian Signature Date
Authorization for Release of Information: I authorize Charlotte Community Health Clinic to release to my insurance carrier or its designated agents any
information concerning medical care (physical and/or psychological), advice, treatment or supplies provided to me for the purposes of administration,
review, investigation or evaluation of claim coverage and utilization of services. I authorize that a copy of this information to be as valid as the original.
I will notify Charlotte Community Health Clinic in writing of any information I do not want released.
________________________________________________________________________ __________________
Patient/Guardian Signature Date
Patient Acknowledgement of Receipt of Notice of Privacy Practices and Patient Rights and Responsibilities: I acknowledge that I have received and been
given an opportunity to read a copy of the Charlotte Community Health Clinic’s Notice of Privacy Practices and Patient Rights and Responsibilities.
__________________
_______________________________________________________________________
Patient/Guardian Signature
Date
