****IN AN EMERGENCY****

HOUSEHOLD INFORMATION: INCOME INCLUDED: GROSS WAGES, SS INCOME, RAILROAD RETIREMENT, UNEMPLOYMENT COMP, STRIKE BENEFITS, WORKER’S COMP, PUBLIC ASSISTANCE, VETERAN’S PAY, CHILD SUPPORT, ALIMONY, INSURANCE OR ANNUITY PAYMENTS, ETC. **WRITTEN DOCUMENTATION FOR ALL SOURCES OF INCOME, FOR ALL HOUSEHOLD MEMBERS MUST BE PROVIDED**

****IN AN EMERGENCY****

IN ORDER TO ASSIST US IN PROVIDING YOU MEDICAL CARE, PLEASE ANSWER THE FOLLOWING QUESTIONS:

IN CASE OF AN EMERGENCY WHO WOULD YOU LIKE US TO DISCUSS YOUR MEDICAL INFORMATION WITH?

This is a self-declaration to show your eligibility to receive a sliding fee scale discount on charges incurred as a result or treatment at any location of Franklin Primary Health Center, Inc. All household income must be reported to be considered. Income may be from any one or combination of the following sources: 1. Employment 2. Unemployment Compensation 3. Public Assistance (TANF, etc.) 4. Child Support, Alimony, regular monetary gifts from family or friends. 5. Interest income from savings, checking, Christmas savings 6. U.S. Savings Bonds, stocks or bonds of any kind 7. Pensions, annuities, retirement funds, etc. (This includes benefits you may receive from being a beneficiary of life insurance or retirement) 8. Social Security or disability income. 9. ANY OTHER INCOME (includes tips, property sold, babysitting, etc.)

FRANKLIN’S PATIENT RIGHTS AND REPSONSIBILITIES, NOTICE OF PRIVACY PRACTICES AND GRIEVANCES POLICIES HAVE BEEN EXPLAINED TO ME AND I HAVE RECEIVED A COPY. I HAVE ALSO BEEN INFORMED THAT IF I HAVE A COMPLAINT OR EXPERIENCE ANY PROBLEMS DURING MY VISIT TO ASK FOR THE OFFICE MANAGER.

I do hereby swear and affirm that the above checked statement is true and correct. The process of qualifying for the sliding fee scale discount was explained to me. Should I have additional questions, I have been instructed to consult the intake clerk, the office manager or a clerk in the billing department.

ASSIGNMENT AND RELEASE: I, THE UNDERSIGNED CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT, I CONSENT TO ANY SERVICES RENDERED TO ME OR MY DEPENDENTS UNDER DOCTOR’S ORDERS. I AUTHORIZE PAYMENT OF HEALTHCARE BENEFITS TO FPHC, INC. I UNDERSTAND THAT I AM FINANCIALLY REPONSIBLE FOR ALL CHARGES AND REFERENCE LAB FEES NOT PAID BY INSURANCE. I HEREBY AUTHORIZE FPHC, INC., TO RELEASE ALL INFORMATION NECESSARY TO SECURE PAYMENT OF BENEFITS.

About Our Notice of Privacy Practices

We are committed to protecting your personal health information in compliance with the law. Our 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 require by law to give you a copy of our Privacy Notice and to obtain your written acknowledgment that you have received a copy of this notice. As a courtesy to our patients we are supplying everyone with a copy of the Advance Directives.

Patient Acknowledgement of Receipt

Patient Questionnaire

Patient Questionnaire

PATIENT SATISFACTION SURVEY

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for your time.