Patient Registration Forms

Patient Registration Form

United Community Health Center
Para ver este formulario en español, haga clic en el menú desplegable en la esquina superior derecha.
Thank you for choosing United Community Health Center as your healthcare provider!

You asked.... we listened!

We are excited to bring you positive changes to our Registration process based upon feedback we have received on our Patient Surveys. We realized filling out registration forms can be tedious and time consuming, so we switched platforms to make the process easier for you.

You will no longer have to fill out brand new registration forms from scratch every year. This new platform will allow us to resend you the form you previously filled out, with all your information prepopulated. All you have to do is review the information, make updates if needed and resubmit it! This will require that you provide us with a valid email address.

We have also condensed the number of forms you need to fill out. Yay!

Keep in mind, with this switch, we do need initial registration forms to be filled out so we have your information stored in the new platform. Then when we need updated information from you next year, or when your information changes, we can send you your prefilled form and all you have to do is change what needs to be updated.

I hope you are as excited as we are!

With that being said, if this form is blank, we need your initial information. If the form is prefilled, then please review the information and change anything that needs to be updated and resubmit it.
I agree to send pre-registration forms electronically to UCHC. I agree to fill out all information as accurately as possible. I understand that all information submitted is protected and follows all HIPAA guidelines. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.*

I accept
Today's Date*

MonthDayYear

Dental History
When was your last dental visit?*
Enter n/a if not applicable
Name of your last Dental Provider/Clinic?*
Enter n/a if not applicable
Have you had any previous dental surgeries?*

YesNo
Have you recently been seen by a dental specialist?*

YesNo
Has a previous dentist ever recommended treatment to you that you did not receive?*

YesNo
If so, why did you not receive treatment?

Emergency Info and Consent
HIPAA Authorization

HIPAA Authorization permits us to disclose patient health information to authorized individuals. In a non-emergent/or emergent situation, a UCHC staff member may discuss, or distribute in writing, my health information, to include lab results, radiology results, medication, and medical conditions. Biological/Custodial guardians are automatically HIPAA Authorized. If you have legal paperwork that says otherwise, please call our office.

Responsible Party and/or Policy Holder should be listed as Emergency Contact with HIPAA authorization if patient would like us to be able to disclose healthcare and insurance information with them.

Responsible Party - Person responsible for paying the patient portion of billed services and receiving billing statements. Policy Holder - Person responsible for patient's insurance.
If patient is UNDER 18 please complete Parent/Guardian Name. (1)*

Parent/Guardian (1) First NameParent/Guardian (1) Last Name
Parent/Guardian (1) Phone Number *
Parent/Guardian (1) Phone Number
Parent/Guardian (1) Date of Birth *

MonthDayYear
Parent/Guardian (1) DOB
If patient is UNDER 18 please complete Parent/Guardian. (2)

Parent/Guardian (2) First NameParent/Guardian (2) Last Name
Parent/Guardian (2) Phone Number
Parent/Guardian (2) Phone Number
Parent/Guardian (2) Date of Birth

MonthDayYear
Parent/Guardian (2) DOB
Emergency Contact(s)

Emergency contacts are NOT authorized to discuss healthcare information unless they are marked as HIPAA below. If they are not marked as 'Yes' then they are not authorized to discuss healthcare, schedule appointments, or collect documents for patient. Responsible Party and/or Policy Holder should be listed as Emergency Contact with HIPAA authorization if patient would like us to be able to discuss healthcare and insurance information with them.
EMERGENCY CONTACT (1)

First Name Last Name
Emergency Relationship to Patient (1)
Emergency Contact Phone Number (1)
Please enter a valid phone number.
Make this emergency contact HIPAA authorized? (1)
EMERGENCY CONTACT (2)

First Name Last Name
Emergency Relationship to Patient (2)
Emergency Contact Phone Number (2)
Please enter a valid phone number.
Make this emergency contact HIPAA authorized? (2)
I acknowledge that the patient listed on this form has no emergency contacts*

I agree
Additional HIPAA Authorized Persons

Add any additional HIPAA authorized persons here
Additional HIPAA Authorized Person (1)

First Name Last Name
HIPAA Relationship to Patient (1)
HIPAA Authorized Phone Number (1)
Please enter a valid phone number.
Additional HIPAA Authorized Person (2)

First Name Last Name
HIPAA Relationship to Patient (2)
HIPAA Authorized Phone Number (2)
Please enter a valid phone number.

Authorization to Consent to Treatment of a Minor

This authorizes the following name(s) as my agent to consent to any medical evaluation and/or treatment, immunizations, x-ray examinations, anethesia, fluoride treatments, dental sealants, surgery evaluation and/or treatment, diagnosis or care which is deemed advisable by and is to be rendered under, the general or special supervision of a licensed physician. This authorization includes hospital admission if such is deemed necessary by the physician. It is understood that this authorization is given to provide authority and power on the part of my aforesaid agent(s) to give specific consent to any and all such evaluation, diagnosis, office treatment, anethestic administration or surgical treatment(s) which a physician, in the exercise of his/her best judgement, may deem advisable.

Any additions or changes to any medication(s) must be discussed with a parent or legal guardian.

This authorization shall remain in effect for ONE YEAR from signed date below, unless revoked in writing, delivered to United Community Health Center, Inc.
Note:

Emergency Contacts listed on this form does NOT automatically authorize them to be able to consent to treat. If you would like emergency contacts to have the authorization to consent for treatment, please list them below.

Legal parents/guardians are automatically authorized to consent for treatment and do NOT have to be listed below.
Parent/Guardian Name*

First NameLast Name
Authorized Name (1)

First NameLast Name
Authorized Relationship (1)
Relationship to patient
Authorized Name (2)

First NameLast Name
Authorized Relationship (2)
Relationship to patient
Authorized Name (3)

First NameLast Name
Authorized Relationship (3)
Relationship to patient

Circle of Care

Our main goal is to keep you safe and to make sure that all providers involved in your care are aware of changes that affect your health. This communication between specialists allows us to refer you to your specialist if the need arises. This form is to list any specialists that are currently involved in your care. Please list CURRENT Providers/Specialists involved in your care. Note: It is IMPORTANT that we have this form on file as part of Continuity of Care guidelines, for current and previous records to be requested.
Primary Dental Clinic and Provider
Dental Clinic and Provider
Previous Clinic/Provider (PCP)
Clinic Name/Provider (PCP)
Previous Clinic/Provider phone number
Previous Clinic/Provider phone number
Last PCP Visit Date
Clinic/Provider (1)
Clinic Name/Provider (1)
Clinic Specialty (1)
Clinic Specialty (1)
Clinic/Provider Phone Number (1)
Clinic Phone Number (1)
Clinic/Provider (2)
Clinic Name/Provider (1)
Clinic Specialty (2)
Clinic Specialty (2)
Clinic/Provider Phone Number (2)
Clinic Phone Number (2)
Does patient have specialty providers other than those listed above?*

YesNo

Circle of Care

Continued
Clinic/Provider (3)
Clinic Name/Provider (3)
Clinic Specialty (3)
Clinic Specialty (3)
Clinic/Provider Phone Number (3)
Clinic Phone Number (3)
Clinic/Provider (4)
Clinic Name/Provider (4)
Clinic Specialty (4)
Clinic Specialty (4)
Clinic/Provider Phone Number (4)
Clinic Phone Number (4)
Clinic/Provider (5)
Clinic Name/Provider (5)
Clinic Specialty (5)
Clinic Specialty (5)
Clinic/Provider Phone Number (5)
Clinic Phone Number (5)
Clinic/Provider (6)
Clinic Name/Provider (6)
Clinic Specialty (6)
Clinic Specialty (6)
Clinic/Provider Phone Number (6)
Clinic Phone Number (6)

Telemedicine Consent and Waiver
This is an optional service to our patients.

United Community Health Center is proud to offer Telemedicine services to our community!

This means we still need to know all the medications you are on so please have all your medication bottles out before your appointment. Medical staff will go through each medication and dosage with you.

Also, we are asking if you can weigh yourself and take your temperature to please do so before your appointment. If you have the ability to take your own blood pressure, to do that as well. Medical staff will ask you for this information at the start of your video appointment.

Like an in-office appointment, there may be a copay associated with this appointment. Please call your insurance company to confirm covered benefits for telemedicine services. You will be responsible for any outstanding charges and copays not covered by your plan. This copay can be paid via our Portal, made over the phone, or a bill can be mailed to you. We encourage you to use our Portal as it is a convenient way to pay your bill and communicate with our staff. If you need help getting set up, let our staff know.

It is very important that we collect necessary information before your scheduled appointment. We may need updated consent forms, registration forms, copies of insurance cards or IDs; in the case that your Provider will need to order labs or diagnostic imaging.

United Community Health Center is looking forward to 'chatting' with you!

1. I understand that if I choose to have a Telemedicine appointment, Telemedicine technology will be used to connect me to the office electronically without the need for me to come into the clinic. Telemedicine appointments may be conducted by videoconferencing, video images, still (high quality photo) images, or by telephone conference.

2. I understand that if I choose to have a Telemedicine appointment, this appointment will not be the same as a direct patient/healthcare provider visit due to the fact that I will not be in the same room as my healthcare provider.

3. I understand if I choose to have a Telemedicine appointment, there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my healthcare provider or I can discontinue the Telemedicine appointment if it is felt that the videoconferencing connections are not adequate for the situation. I understand that I can discontinue the Telemedicine appointment at any time.

4. I understand that if I choose to have a Telemedicine appointment, my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the appointment other than my healthcare provider in order to operate the equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence during the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the Telemedicine examination room; and/or (3) terminate the Telemedicine appointment at any time.

5. I understand if I choose to have a Telemedicine appointment, in an emergency situation, I understand that the responsibility of the provider may be to direct me to emergency medical services, such as emergency room. Or the Telemedicine provider may discuss with and advise a specialty provider. The Telemedicine specialist’s or provider’s responsibility will end upon the termination of the Telemedicine connection.

6. I understand that if I choose to have a Telemedicine appointment, billing for the Telemedicine consultation will occur from the primary care provider in the same manner as an in office visit. Billing is at the discretion of the provider.

7. I understand not every type of appointment qualifies for a Telemedicine appointment and that sometimes coming into the office will be necessary

8. I have read this document carefully, and understand the risks and benefits of the Telemedicine appointment and have had my questions regarding the procedure explained.
I hereby consent to participate in a Telemedicine appointment visit, if I choose, under the terms described herein.*

I understand

Notice of Health Information Practices
You are receiving this notice because your healthcare provider participates in a non-profit, non-governmental health information exchange (HIE) called Health Current, a Contexture company. It will not cost you anything and can help your doctor, healthcare providers, and health plans better coordinate your care by securely sharing your health information. This Notice explains how the HIE works and will help you understand your rights regarding the HIE under state and federal law.

How does Health Current help you to get better care?
In a paper-based record system, your health information is mailed or faxed to your doctor, but sometimes these records are lost or don’t arrive in time for your appointment. If you allow your health information to be shared through the HIE, your doctors are able to access it electronically in a secure and timely manner.

What health information is available through Health Current?
The following types of health information may be available:
• Hospital records
• Radiology reports
• Medical history
• Clinic and doctor visit information
• Medications
• Health plan enrollment and eligibility
• Allergies
• Lab test results
• Other information helpful for your treatment

Who can view your health information through Health Current and when can it be shared?
People involved in your care will have access to your health information. This may include your doctors, nurses, other healthcare providers, health plan and any organization or person who is working on behalf of your healthcare providers and health plan. They may access your information for treatment, care coordination, care or case management, transition of care planning, payment for your treatment, conducting quality assessment and improvement activities, developing clinical guidelines and protocols, conducting patient safety activities, and population health services. Medical examiners, public health authorities, organ procurement organizations, and others may also access health information for certain approved purposes, such as conducting death investigations, public health investigations and organ, eye or tissue donation and transplantation, as permitted by applicable law.

Health Current may also use your health information as required by law and as necessary to perform services for healthcare providers, health plans and others participating with Health Current.

The Health Current Board of Directors can expand the reasons why healthcare providers and others may access your health information in the future as long as the access is permitted by law. That information is on the Health Current website at healthcurrent.org/permitted-use.

You also may permit others to access your health information by signing an authorization form. They may only access the health information described in the authorization form for the purposes stated on that form.

Does Health Current receive behavioral health information and if so, who can access it?
Health Current does receive behavioral health information, including substance abuse treatment records. Federal law gives special confidentiality protection to substance abuse treatment records from some substance abuse treatment programs. Health Current keeps these protected substance abuse treatment records separate from the rest of your health information. Health Current will only share these protected substance abuse treatment records it receives from these programs in two cases. One, medical personnel may access this information in a medical emergency. Two, you may sign a consent form giving your healthcare provider or others access to this information.

How is your health information protected?
Federal and state laws, such as HIPAA, protect the confidentiality of your health information. Your information is shared using secure transmission. Health Current has security measures in place to prevent someone who is not authorized from having access. Each person has a username and password, and the system records all access to your information.

Your Rights Regarding Secure Electronic Information Sharing
You have the right to:
1. Ask for a copy of your health information that is available through Health Current. To make this request, complete the Health Information Request Form and return it to your healthcare provider.

2. Request to have any information in the HIE corrected. If any information in the HIE is incorrect, you can ask your healthcare provider to correct the information.

3. Ask for a list of people who have viewed your information through Health Current. To make this request, complete the Health Information Request Form and return it to your healthcare provider. Please let your healthcare provider know if you think someone has viewed your information who should not have.

You have the right under article 27, section 2 of the Arizona Constitution and Arizona Revised Statutes title 36, section 3802 to keep your health information from being shared electronically through Health Current:

1. Except as otherwise provided by state or federal law, you may “opt out” of having your information shared through Health Current. To opt out, ask your healthcare provider for the Opt Out Form. Your information will not be available for sharing through Health Current within 30 days of Health Current receiving your Opt Out Form from your healthcare provider.
Caution: If you opt out, your health information will NOT be available to your healthcare providers—even in an emergency.

2. If you opt out today, you can change your mind at any time by completing an Opt Back In Form and returning it to your healthcare provider.

3. If you do nothing today and allow your health information to be shared through Health Current, you may opt out in the future.

IF YOU DO NOTHING, YOUR INFORMATION MAY BE SECURELY SHARED THROUGH HEALTH CURRENT.

Patient Practices/Rights & Responsibilities

I understand the UCHC Notice of Privacy Practices and patient rights and responsibilities, which contain a description of the uses and disclosures of my health information and my rights and responsibilities as a UCHC patient. I understand that this organization has the right to change its Notice of Privacy Practices from time to time, and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices. I may also obtain a printed copy of my rights and responsibilities at any time. I understand that my medical and dental information, if both services are used, will be available to both medical and dental providers at UCHC and may be used for treatment purposes.
People involved in your care will have access to your health information. This may include your doctors, nurses, other healthcare providers, health plan and any organization or person who is working on behalf of your healthcare providers and health plan. They may access your information for treatment, care coordination, care or case management, transition of care planning, payment for your treatment, conducting quality assessment and improvement activities, developing clinical guidelines and protocols, conducting patient safety activities, and population health services. Medical examiners, public health authorities, organ procurement organizations, and others. I understand the Notice of Health Information Practices regarding my providers participation in Contexture, previously Health Current, the statewide Health Information Exchange (HIE). I understand that I can request a copy at any time. United Community Health Center may obtain/send prescription/medication history from/to external sources. Often times medication names change and doses get adjusted for you by other providers. By requesting this information directly from the pharmacy, we are better able to protect you, the patient, from inaccurate medication refill and dosing corrections as well as potential harmful drug interactions. If you wish to opt out, contact our Patient Advocate line at 520-407-5970.

I acknowledge that I received and read the Notice of Health Information Practices. I understand that my healthcare provider participates in Contexture, Arizona’s health information exchange (HIE). I understand that my health information may be securely shared through the HIE, unless I complete and return an Opt Out Form to my healthcare provider.

We are committed to providing the best possible care for you, and as part of this commitment we are continually looking for ways to enhance our services. Your provider may utilize AI Services to improve quality of your care. If you wish to opt out, please see a staff member.

Receiving timely medical, dental, and behavioral health services is necessary to maintain good health and avoid complications and exacerbations. United Community Health Center is committed to providing high quality care to all of our patients and we are making every effort to minimize the risk of exposure to all types of infectious diseases. However, despite our best efforts, inevitably certain inherent risks are beyond the control of the UCHC and our staff. This Risk Acknowledgement is intended to ensure that patients and families are aware of, and accept the inherent risks associated with the COVID19 pandemic, and the inability to eliminate or fully control such risks.

The virus that causes COVID-19 is thought to spread from person to person, mainly through respiratory droplets produced when an infected person coughs or sneezes. Spread is more likely when people are in close contact with one another (within 6 feet).

COVID-19 guidance from the CDC and Pima County Health Department experts and agencies, continues to evolve. UCHC takes various precautions to protect patients and staff from COVID19, in line with such guidance. Such precautions include, but are not limited to, regularly scheduled cleaning and disinfectant procedures completed in all areas of our facilities. Staff and visitors are required to wear face coverings if experiencing any symptoms. Increased hand sanitizer stations are available throughout the clinical areas. Hand washing and personal protective equipment standards continue to be the main staple of infection control.

Consent for Treatment

I hereby authorize the physicians and mid-level providers of United Community Health Center to administer medications, perform examination and diagnostic procedures. This consent will remain in effect until such time I notify United Community Health Center in writing of termination of said consent.

Statement of Financial Responsibility

I hereby authorize United Community Health Center to furnish information necessary to the payor(s) concerning all services for which I seek treatment and hereby irrevocably assign United Community Health Center all payments for medical, behavioral, and dental services rendered. If I qualify, I may receive discounts based on the sliding fee scale. I agree to provide accurate insurance information and pay any remaining balances, including co-pays, deductibles, or uncovered services. I understand that I am financially responsible for all charges whether covered by my third-party payer(s). Payment is due at the time of service unless other arrangements are made. Unpaid balances may result in collection efforts.
You will automatically be enrolled in receiving paper statements, unless you choose to opt out. Only web-enabled patients can opt out of paper statements. Statements will continue to be sent electronically.*

I choose to OPT OUT of receiving paper statements (must be web-enabled)I still want to receive a paper statement in addition to being sent electronically
You must accept to submit electronically*

I accept

United Community Health Center (UCHC)

Acknowledgement of Patient Responsibility

Refusal to Pay Notice

UCHC is a non-profit organization whose mission is to serve the health care needs of those in our communities. We depend on all patients to fulfill their payment obligations to continue providing dependable, quality health care to you and other patients. UCHC has a Refusal to Pay policy, this policy will go into effect after 60 days past due balance has not been addressed or if patient voices that they will refuse to pay. UCHC does offer payment plans if needed. If no efforts have been made by the patient or guardian to pay on balances over 60 days, this is deemed refusal to pay and UCHC will explore possible discharge of the patient from UCHC.

Coordination of Benefits

All patient insurance information must be provided to UCHC at appointment check in. Coordination of Benefits (COB) should be set up with your insurances before you are seen by our providers to ensure all claims will be paid and not denied for Coordination of Benefits. This is the patient's responsibility. If claim is denied for Coordination of Benefits, the patient may be responsible for the cost of the visit. This form is to acknowledge that the patient has been made aware that this is patient’s responsibility of the above and that patient has provided all insurance information to UCHC including insurance cards at the time of service.

VISIT TYPES (Preventive & Sick)

PREVENTIVE visit type targets preventive care and are billed as such. This type visit is an office visit for preventive care. Medication refills and/or acute conditions addressed during the preventive visit are billed IN ADDITION to the preventive visit.

SICK visit type, this is an office visit for an acute or follow up for a chronic problem that requires additional treatment such as labs, x-rays, medication, or referrals.

SICK/PREVENTIVE VISIT, this is a combination visit of preventive services (like Annual Physical, Well Visit, Annual Wellness Visit) and where an acute or chronic issue is also addressed during the same visit. For example, if you presented today for a preventive visit and have an acute issue you would like addressed, it is considered a combination visit and must be billed differently than just a preventive visit. WHY IT IS BILLED DIFFERENTLY is because it requires additional documentation and in addition may also require additional work, expertise and time required for a combination visit (additional lab work, x-ray, referrals and/or prescription medications).

HOW THIS AFFECTS THE PATIENT Some insurances will require a co-pay or have additional costs applied to his/her annual deductible for the additional services. Checking with your insurance carrier will help you better understand the differences.

Motor Vehicle Accident Visits

The patient will need to provide motor vehicle insurance information to UCHC when scheduling. These visits can and will only include treatment and discussion pertaining to the MVA. Treatment for any other condition other the MVA injury will need to be scheduled on a separate visit.

If no motor vehicle insurance information is provided or if the MVA insurance denies payment or does not fully cover the charges, UCHC will attempt to bill the patient’s medical insurance, if any. If the patient does not have medical insurance, if the claim is denied by the patient’s medical insurance, or if patient’s medical insurance does not pay within 3 months of submission of the claim, the patient will be billed directly and responsible for the visit.

Sports/Camp Physical Acknowledgement

I understand that a Sports/Camp Physical is not a covered benefit on my child's insurance plan. I accept the cost of $33.00 for the exam to be completed by a UCHC provider.

Insurance Card(s)

It is crucial to keep your medical records, personal information, and insurance information up to date. Providing complete and accurate information will benefit you, as a patient, because it makes billing flow more accurately.

We, like any other medical facility, need to request your insurance card and ID along with updated contact information to ensure our records are accurate and will need to update your records annually. Filling out the patient paperwork in its entirety is vital in preventing errors and will decrease the risk of a medical visit denial for payment, in turn making it possibly your responsibility for payment. If you have moved, changed phone numbers or insurances please notify our clinic so your billing/chart information is correct.
I understand that if I choose not to upload a copy of my ID and Insurance Card(s), that I will be sent a separate upload form requesting this information. I understand that if I choose not to electronically upload my photo ID and/or Insurance Card(s) that I will bring them with me to each of my appointments so that staff can verify the information and take copies if needed.*

I understand
I understand that Medicare information as well as any Advantage or Supplemental Plan I have will be needed to properly bill my insurance for any services rendered.*

I understand
A physical copy of active insurance cards are needed annually. I understand if UCHC does not have a current copy an active insurance card, I may be responsible for the full bill and may be required to work out a payment arrangement. I understand that I may be charged for all medical services which may include doctor fees, labs, tests, and immunizations/vaccines. I understand that I may be fully responsible for any referrals to specialists. I understand that I will be marked as ‘self pay’ until an active insurance card is obtained and entered into my Medical Record Chart.*

I understand
Upload a copy of the FRONT and BACK of your Photo ID and ALL Insurance Cards

Uploading this information will speed up the Registration process. If you don't have the ability to scan your cards, you can take a picture with your cell phone and upload the photo(s). Be sure to take a photo of the front and back of your insurance card. If you do not have the ability to upload copies electronically, bring your photo ID and all insurance cards with you to your appointments and our staff will be happy to scan them for you.
Cancelof
By signing, you agree your electronic signature is the legal equivalent of your manual/handwritten signature. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.
SIGNATURE (must be VALID LEGAL Name or this form will be INVALID)*

First NameLast Name
Signer's Relationship to Patient*
Upon submitting this form you will automatically be redirected to upload current copies of your Insurance Card(s) and Photo ID. If you have more than 1 Insurance Card, upload each separately.
Today's Date*

MonthDayYear
Please verify that you are human*
Should be Empty:

Patient Registration Form

Para ver este formulario en español, haga clic en el menú desplegable en la esquina superior derecha.

Patient Information

Medical Insurance Information

If you are interested in applying for our Sliding Fee Discount Program, call Enrollment at 520-777-3912 to see if you qualify.

Dental Insurance Information

If you are interested in applying for our Sliding Fee Discount Program, call Enrollment at 520-777-3912 to see if you qualify.

Dental History

Patient Demographics

Emergency Info and Consent

Emergency Contact(s)

Additional HIPAA Authorized Persons

Circle of Care

Circle of Care

Telemedicine Consent and Waiver

Notice of Health Information Practices

Patient Practices/Rights & Responsibilities