Manet CHC Registration Form
Date of Birth:
Social Security #:
Please check if you are:
Are you head of household?
Number of Dependents:
Do you have insurance?
Please select the patient's relationship to Insurance Card Holder:
Name of person who gets this insurance:
Subscriber's date of birth:
Subscriber's telephone #:
Name of Insurance Plan:
Doctor or Health Center Name listed on your card:
SECOND INSURANCE PLAN:
If patient is a child:
Billing Address (if different from above address):
PERSON YOU WANT CALLED IN AN EMERGENCY:
I hereby authorize the staff of Manet Community Health Center, Inc., to render such services as deemed necessary to me/my child listed above. I also authorize the release of all necessary information to insurance companies and other payers and assign to Manet Community Health Center, Inc. the authority to claim and collect insurance benefits. I will be financially responsible for any charges incurred for services not covered by my insurance plan. I acknowledge that I have received notice that I may receive a copy of Manet Community Health Center's Patients Privacy Rights and the Privacy Policies and Practices upon request. I give my consent for the use of telehealth in my medical care and I understand that a copy of the Telehealth Policy can be provided upon request.
Indicate relationship if 'other':
MRN (internal use only): _________
Date of birth:
What is the best phone number to reach you for tests results?
Can we leave a voice mail if your test result is negative?
Which race/ethnicity best describes you?
Are you experiencing any new onset (within 1-2 weeks) of the following symptom(s)? Check all that apply:
For the past days, I have been having the following symptom(s): (check all that apply)
Manet Community Health Center, Inc. | * 6587534w4368 A-HIPAA
Manet Community Health Center will use and disclose your personal health information to treat you, to receive payment for the care we provide, and for other health care operations. We have prepared a detailed NOTICE OF PRIVACY PRACTICES to help you better understand our policies in regard to your personal health information. You have the right to review this notice prior to signing this acknowledgement. The terms of this notice may change with time and we will always post the current notice at our facilities and have copies for distribution. You may ask us to restrict the use and disclosure of your personal health information. However, we are not required to agree to such a request, but if we do agree, we are bound by law to the agreed upon restrictions.
There are times when our patients request that their health care provider include a friend or member of their family in their health care decisions. Please list any family member or friend to whom we may speak or share your personal health information (PHI).
The health center staff has my permission to leave personal health information as a message on my answering machine.
The health center staff has my permission to share my personal health information with the following person(s):Name Relationship Phone
Name Relationship Phone
Patient Date of Birth:
Name of patient or legal representative:
Relationship to Patient
Please provide email address for Patient Portal:
For internal use only:
MCHC has made a good faith effort to obtain the patient's acknowledgement, but the patient's signature was not obtained for the following reason(s): __________________________________________________________________________________________
Staff Signature: _____________________________________________
Date of Birth:
I hereby authorize Manet Community Health Center, Inc. to send my health information from: (Please list below)
Name (of facility):
Format of information to be released:
I wish to pick up my records: (medical records will contact you when ready for pick-up)
Please specify information to be released or obtained. Check all that apply. Only checked items will be released.
Release of information regarding specific consent. The following categories of information in your medical record will not be released without your specific authorization, indicated by initialing each appropriate category:
Sexually Transmitted Disease
Rape Sexual Assault
Purpose for requested Information: Purpose
By signing this authorization, I understand that:
This authorization will remain in effect for 90 days after the above date or as specified:
Requests for copies of medical records are subject to reproduction fees in accordance with federal/state regulations
I have the right to revoke this authorization at any time. Revocation must be made in writing to the Medical Records Department. Revocation will apply to information that has already been disclosed in response to the authorization.
Treatment, payment, enrollment or eligibility for benefits many not be conditioned on whether I sign this authorization
I also understand that this information may be re-disclosed by the recipient if the recipient is not required to follow the privacy regulations or statutes.
I have read and understand the terms of this authorization.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Manet CHC Registration Form
Agree & Sign