Dental Patient Registration Form

DENTAL PATIENT REGISTRATION FORM
Dental Clinic Location:*
Name*

First NameMiddle InitialLast Name
Preferred Name
Date of birth*

MonthDayYear
Date
Email Address*
example@example.com
Address*

Mailing Address

Street Address Line 2

CityState

Zip
Marital status*

DivorcedMarriedSingleDomestic PartnerSeparatedWidowedSignificant Other
Sex at Birth*

MaleFemaleNot RecordedIntersexUnknownDecline
Social Security Number*
Preferred Pharmacy*
Cell Phone*
Home Phone
Emergency Contact Name*
Phone Number*
Please enter a valid phone number.
Relationship to Patient*
Responsible Party Information
Relation to Patient:*
Relation to Patient if Other:
Name*

First NameLast Name
Social Security Number
Employer*
Address*

Street address

Street Address Line 2

CityState

Zip
Date of birth*

MonthDayYear
Date
Phone Number*
Gender*
Insurance
Same as Patient/ Responsible Party
Insurance company*
Subscriber First and Last Name*
Employer*
Policy holder's date of birth*

MonthDayYear
Date
Insurance Policy Number*
Policy holder's social security #*
HEALTH CENTER FUNDING INFORMATION
In order to continue the variety of services that we offer here at RCH and to continue to receive grant funding, we are required to collect the following information on
every person that visits our facility. This information is reported as a cumulative number and not reported on individual patients.
Employment Status*

Employed Full timeEmployed Part timeUnemployedRetiredDisabledChoose not to disclose
Employer Name*
Household Annual Income (Family Annual Income)*

Less than $10,000$10,000-14,999$15,000-19,999$20,000-29,999$30,000-39,999$40,000-49,999$50,000 -59,999$60,000- 69,999$70,000-79,999$80,000-89,999$90,000-99,999+100,000Choose not to disclose
How many people in your family? *
(yourself, spouse and minor children under 18 years)
Referral Source*

BillboardRadioBusiness/AgencyFriend or FamilyHospital/ClinicInternet Search/ NewspaperSocial MediaFair/Festival/EventChoose not to disclose
Veteran Status*

VeteranNot a VeteranChoose not to disclose
Student Status*

Full TimePart TimeNot a StudentChoose not to disclose
Agricultural Status over the last 3 years*

MigrantSeasonalNoChoose not to disclose
Homeless Status*

ShelterTransitional HousingStreetNoChoose not to disclose
Preferred Language*
Do you need an Interpreter?*

YesNo
What pronouns do you use? **Only if over 12 years of age*

He/Him/HisShe/Her/HersThey/Them/TheirsChoose not to discloseUnknown
What is your gender identity? **Only if over 12 years of age*

MaleFemaleNon-Binary/GenderqueerTransgender/Male to FemaleTransgender/Female to MaleTwo SpiritOtherChoose not to disclose
Sexual Orientation: **Only if over 12 years of age*

Straight or heterosexualBisexualGayLesbianPansexualQueerOmnisexualAsexualSomething ElseChoose not to disclose
What race would you identify as?*

African American/ BlackCaucasian/WhiteAlaskan NativeNative AmericanPacific IslanderAsianOtherChoose not to disclose
Ethnicity*

Hispanic/Latino/LatinaNon-Hispanic/Latino/LatinaChoose not to disclose
Signature*

Clear
Date*

MonthDayYear
Date
AGREEMENT: PLEASE READ CAREFULLY AND SIGN AT THE BOTTOM
Consent for Treatment:
I consent to treatment necessary for the care of the above named patient. I authorize release of all medical records to referring health care providers and to my insurance company, if applicable. I authorize fax transmittal and/or HIPAA secure electronic submission of my medical record, if necessary.
Advance Directive:*

Yes, I have an Advanced DirectiveNo, I don't have an Advanced Directive
Location (if you marked yes above)*
Please provide me with information about an Advance Directive:*

YesNo
Medical Home:
I understand that Rogue Community Health's model of care is a Patient Centered Medical Home. This means Rogue Community Health is my health care setting where either my family or I work in partnership with our care team to address all our health care needs. Treatment is provided using a team approach and at times may include assistance from Integrated Behavioral Health (IBH) clinicians. As part of your treatment team, IBH clinicians may be asked to step in to assist with
your care specific to mental and/or behavioral health needs. Your signature on this Agreement is an acknowledgement that you are aware of this service and that you are consenting to treatment as needed wit ices at any time.
Rogue Community Health is my Medical Home*

YesNo
Financial Responsibility:
All insurance co-pays are due at the time of the visit. All patients with self-pay accounts must bring cash payment at each visit. Patients that have made payment arrangements and/or received a monthly statement must make a payment within thirty days of the statement date. If you have payment concerns, please notify the billing department. We will bill your insurance for you. However, your account remains your responsibility.

Insurance Authorization:
I understand the financial policy above and accept financial responsibility. By this agreement, I assign Rogue Community Health all payments due from my insurance company for services rendered.

Release of Information: If unable to reach me you may: *

	Yes	No	N/A
Leave a detailed message on my answering machine at home
Leave a detailed message on my cell phone
Leave a detailed message at my place of employment
Discuss my medical condition with members of my household
Discuss my medical scheduling with members of my household

Name of household member:

First NameLast Name
Relationship:
Phone Number
Please enter a valid phone number.
Name of household member:

First NameLast Name
Relationship:
Phone Number
Please enter a valid phone number.
Consent to Request Medical Care for Minors:
The following persons are authorized to access medical care for the child named above, for services not related to well-child or preventive services:
Name

First NameLast Name
Relationship:
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship:
Phone Number
Please enter a valid phone number.
I have read and fully understand the above consent for treatment, financial responsibility, andrelease of medical information, insurance authorization, and consent to request medical care for minors. These agreements will remain in effect for one calendar year or until revoked by me in writing. If revoked, I understand the authorization will not affect any use or disclosure of information that has already occurred.
Patient or Guardian Name*
Signature of Patient or Guardian*

Clear
Relationship to Patient*
Date*

MonthDayYear
Date
CONSENT TO USE OR DISCLOSE MEDICAL INFORMATION
I authorize Rogue Community Health to use and disclose the health and medical information for the purposes of Treatment, Payment, and Healthcare Operations. *
Patient name
*Treatment includes services performed by a provider, nurse, lab personnel, office staff, and other types of healthcare professionals providing care to you, coordinating or managing your care with third parties, and consultations with and between other healthcare providers. This consent includes treatment provided by any medical personnel who covers our practice by telephone as the on-call medical personnel.

*Payment includes activities involved in determining your eligibility for health plan coverage, billing and receiving payment for your health benefit claims, and utilization management activities which may include review of health care services for medical necessity, justification of charges, pre-certification and pre authorization of services.

*Healthcare Operations includes the necessary administrative and business functions of our office. Rogue Community Health is part of an organized health care arrangement including participants in the Oregon Community Health Information Network (OCHIN). Your health information may be shared by Rogue Community Health with other OCHIN participants when necessary for healthcare operations.

*Communications As a patient of Rogue Community Health, you may be contacted via text or voice messaging to remind you of an appointment, to obtain feedback on your healthcare experience with our medical, dental and/or behavioral health teams, and to provide general reminders. I consent to receiving appointment reminders and other healthcare communications via text or voice message from Rogue Community Health at my preferred telephone number and any number forwarded or transferred to that number. I understand that this request to receive text or voice messages will apply to all future appointment reminders/feedback/health information. I further understand that message/data rates may apply to “sent” messages under my cell phone plan.
You may review Rogue Community Health’s “Notice of Privacy Practices” for additional information about the uses and disclosures of information described in this CONSENT prior to signing this CONSENT. Please verify that you have received a copy of our Notice by initialing here:*
Initial here
Rogue Community Health reserves the right to change our privacy practices in accordance with the law which may change the terms contained in the Notice. A summary of the Notice is posted in our waiting room and on our website (www.roguecommunityhealth.org) and includes the effective date of the Notice in the upper right- hand corner. We will offer you a copy of the Notice on your first visit to us after the effective date of the most current Notice. We will also provide you with a copy of the Notice upon your request.

As more fully explained in the Notice, you have the right to request restrictions on how we use and disclose your protected health information for purposes of treatment, payment, and healthcare operations. We are not required to agree to your request. If we do agree with your request, we are required to comply with your request unless the restricted information is needed to provide you emergency treatment. Other medical personnel who provide call coverage for our office are required to use and disclose your protected health information consistent with the Notice.
I agree to the terms stated herein and understand that I have the right to revoke this CONSENT provided I do so in writing to the Compliance Director at compliance@roguech.org, except to the extent that Rogue Community Health has already used or disclosed the information based on this CONSENT.
Patient or Person Authorized by Law*
Signature of Patient (or Signature of Person Authorized by Law) *

Clear
Date*

MonthDayYear
Date
Rogue Community Health Patient Agreement
- I understand that I must treat all staff and clients of Rogue Community Health with dignity and respect.
- I understand that the following behaviors are not acceptable as a Rogue Community Health patient:
  - Verbal abuse or vulgar language
  - Threats or acts of physical violence
  - Fraudulent or illegal activities
  - Medication-seeking behavior
- I understand that weapons are not allowed on RCH property.
- I understand that I should arrive at my specified appointment arrival time.
- I understand I should cancel appointments at least one hour before the appointment time or it will be considered a “No Show.”
- I understand that two (2) “No Shows” within a six-month (6) period could result in losing privileges to schedule future appointments.
- I understand that I can request a copy of all authorization documents such as the Notice of Privacy Practices (HIPAA), Patient Responsibilities, and Rogue Community Health Responsibilities and Duties.
- I understand that children may not be left in the waiting area while I am being treated.
- I understand that payment is due at time of service unless previous arrangement has been made with the Rogue Community Health Billing Department.
- I understand that I will provide Rogue Community Health with any updates on my address, insurance, contact information or any other information that could affect RCH’s ability to provide care.
- I have been given the opportunity to ask any questions I have about my care provided by Rogue Community Health.
- I have taken note that non-custodial parents have the presumptive right to information regarding their minor
  children unless legal documentation has been provided to RCH indicating the loss of parental rights. Additionally, legal guardians acting on behalf of another individual must provide documentation of the legal right to do so. Questions may be directed to compliance@roguech.org or 541.930.5618.
Sign*

Clear
Patient/ Parent/ Legal Guardian Name:*
Date*

MonthDayYear
Date

AGREEMENT: PLEASE READ CAREFULLY AND SIGN AT THE BOTTOM

CONSENT TO USE OR DISCLOSE MEDICAL INFORMATION

Rogue Community Health Patient Agreement

Race, Ethnicity, Language, and Disability (REALD)