Crescent Community Clinic Application for Healthcare Services If you have been diagnosed with a dental concern, a chronic health or mental health condition, you may be eligible for free healthcare at the Crescent Community Clinic. Please review the criteria for chronic health before completing the following application. Please check one or more of the following health issues Arthritis Asthma Cancer COPD Diabetes Epilepsy Heart Disease Hypertension Obesity Urology Depression Bi-Polar Obsessive Compulsive Disorder Personality Disorder Schizophrenia Tooth Pain Oral Infection(s) Tooth Extraction(s) NOTE: The clinic is not able to provide emergency medicine, orthopedic, obstetrics, gynecology, hernia surgery, ophthalmology, rheumatology, vascular surgery or podiatry services at this time. All of the physicians and dentists are volunteers and until other professionals volunteer the clinic is limited. If you checked any of the above diagnoses carefully read and complete the following application. Once the application is received (by mail not fax) you will be scheduled for an appointment to finalize the application process and at that time you will be given an appointment to see a physician or dentist. NOTE: Read and complete the entire application and send in documentation of income. It may be either a W-2 form, previous or current year s copy of the first page only of tax return, food stamp letter, social security income letter/statement, or other documentation. You must meet the federal poverty guidelines to be eligible for services. NOTE: The Clinic does not prescribe any narcotics If you checked one or more of the above health concerns then complete the entire application and mail to Crescent Community Clinic, 5244 Commercial Way, Spring Hill, FL 34606 Please include the documentation for income (may be W-2 form, Social Security, first page of last year s IRS tax return, Unemployment compensation letter, Food Stamp SNAP letter)
Please complete all information below Crescent Community Clinic PATIENT RECORD Name Date of Birth / / / Place of Birth Address City Zip Telephone Cell Email Address Single Married Divorced Primary Language Education Social Security Number Emergency Contact Phone Pharmacy Location Have you or do you plan on applying for disability? Yes No If applied, when did you apply? Did you go through an attorney? Yes NO NOTE: We do not send patient records to your attorney Signature of applicant Date You will be required to provide a copy of your social security card and photo identification at time of interview Patient Bill of Rights Crescent Community Clinic staff shall provide health, dental or mental health care in a courteous and personalized manner, and will do so without consideration of race, color, creed, gender, national origin or the ability to pay. Our volunteer staff shall endeavor to provide for the patient in a professional, confidential and caring manner regarding patient s health problems, treatment to be given, prognosis and in those cases where referrals for additional services outside of the clinic, the reason for such treatment. Volunteer staff shall endeavor to provide privacy for the patient during treatment. Volunteer staff shall endeavor to provide an appointment tie for the patient and the name of the physician who will be responsible for his/her healthcare. Upon request, the volunteer staff will provide information regarding the policies that may affect the healthcare of the patient. Upon request patients will be provided copies of their healthcare records for patient s personal files. Crescent Community Clinic does not participate with any attorney for disability applications or claims. Patient is required to call the clinic to request a copy of their records for their attorney. Patient must pick up healthcare records as we are unable to mail patient records to attorney. Crescent Community Clinic volunteer staff abides by HIPPA regulations. As a patient I agree to notify the clinic at least 24 hours prior to an appointment. I understand that I will be disqualified from receiving services for the following reasons: 1. Non-compliance with following the medical instructions provided to me, including attending health literacy programs on diabetes, smoking cessation and other health issues 2. Failure to notify the clinic when my financial status changes or failure to update my financial information yearly which will result in causing you to be ineligible for services 3. Missed appointment without notifying the office. Message may be left on answering machine at 352-610- 9916 when office is closed I understand and will comply with the policy of the Crescent Community Clinic. Signature of patient Date
Crescent Community Clinic Consent and Release PLEASE READ CAREFULLY I hereby give my expressed consent for all present and future services, treatment and medications prescribed or provided to me by the Crescent Community Clinic volunteer professional staff. I understand that certain procedures, treatment and other activities may be carried out by person)s other than a licensed physician but such activities will be at the direction of a licensed physician. In consideration of said present services and future services, treatment and medication received from the Crescent Community Clinic and without any other representation, promise or agreement oral or written, I hereby fully and completely release and discharge the said Crescent Community Clinic and all parties in interest from claims, demand, grievances and causer of action of every kind and nature whatsoever, including but without limitation of the foregoing, all liability for damages or injuries of every kind, nature description, known or unknown, permanent or otherwise, mow existing or which may hereafter arise from or out of the above mentioned services, treatment or medications received at the Crescent Community Clinic in the State of Florida. I hereby authorize any licensed physician, medical practitioner hospital, clinic or any other medical or medicallyrelated facility, medical information bureau or other organization or person that has any record or knowledge of me or of my health, to give Crescent Community Clinic any such information. I also authorize Crescent Community Clinic to dispense medical information to the aforementioned person, facilities and organization. I have read and understand this consent and release. Signed Date Witnessed by Clinic volunteer staff _ Date
Patient Medical Data Current physician s name Phone Address Fax Are you under a physician s care now? Yes No Do you smoke or use tobacco? Yes No If so, how much do you use tobacco or smoke Are you pregnant? Yes No List your medical conditions and include the medications you are currently taking. Medical Condition Medications Do you have or had any of the following conditions? Yes No Yes No ( ) ( ) Heart Murmur ( ) ( ) Joint Replacement ( ) ( ) Rheumatic Fever ( ) ( ) Diabetes ( ) ( ) Heart Disease Heart Disorder ( ) ( ) Asthma ( ) ( ) High or Low Blood Pressure ( ) ( ) Emphysema/Tuberculosis/COPA ( ) ( ) Pacemaker ( ) ( ) Excessive or Prolonged Bleeding ( ) ( ) Valve Replacement ( ) ( ) Anemia ( ) ( ) Stroke ( ) ( ) Aneurysm ( ) ( ) Artery Stent ( ) ( ) Hepatitis ( ) ( ) Cancer ( ) ( ) Epilepsy ( ) ( ) Kidney or Liver Disease ( ) ( ) Arthritis ( ) ( ) Hearing Problem ( ) ( ) Lactose Intolerant ( ) ( ) Adverse effect to Anesthesia ( ) ( ) Obesity ( ) ( ) Hypertension ( ) ( ) Depression ( ) ( ) Positive for HIV AIDS ( ) ( ) Taking Osteoporosis medication If you answered yes to any medical condition above, please explain below Include any medical condition not listed above List any drug allergies Date Patient Signature
CRESCENT COMMUNITY CLINIC 5244 Commercial Way, Spring Hill, FL 34606 Phone: 352-610-9916 Fax: 352-610-9915 AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION Patient s Name: Date of Birth: Previous Name: Social Security #: I request and authorize to release healthcare information for the patient named above to: This request and authorization applies to: Name: Crescent Community Clinic Address: 5244 Commercial Way, Spring Hill, FL 34606 [ ] Healthcare information relating to the following treatment, condition, or dates: [ ] All healthcare information [ ] Other: Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia non-specific urethritis, syphilis, VDRL, Immunodeficiency Syndrome, and gonorrhea. Yes No I authorize the release of my STD results, HIV/IDS testing, whether negative or positive to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these tests results to anyone. Yes No I authorize the release of any records regarding drug, alcohol or mental health treatment to the person(s) listed above. Patient Signature Date