Combined Patient Registration Form-Research opt out 10/1/22

Native American Community Clinic

Patient Registration
Name*

First NameLast Name
I prefer to be called:
Date of Birth (00/00/0000)*
Legal Sex:*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you live in public housing?*

YesNo
Housing Status:*

HousedTransitiionalHomeless - Living Temporarily with OthersLiving in ShelterUnshelteredOther
Preferred Pronouns:*

she/her/hershe/him/histhey/them/theirsze/hir/hirsey/em/eirsxe/xem/xyrsve/vir/visother
Gender Identity*

Choose Not to DiscloseFemaleMaleNon-binary/genderqueerOtherQuestioningTransgender Female/Male-to-FemaleTransgender Male/Female-to-MaleTwo Spirit
Sexual Orientation*

Choose not to discloseDon't knowAsexualBisexualGayLesbianOmnisexualPansexualQueerStraightSomething else
Phone Number*

Area CodePhone Number
Phone Type:*

CellHomeWorkOther
Email*
Preferred method of communication:*

PhoneMail
Is it okay to call you at and leave a message:*

HomeCellWorkDo not call me
Additional Information
Preferred Language:*

EnglishSpanishHmongRussianSomaliOther
Race (Choose all the apply):*

Alaskan NativeAmerican IndianAsian IndianBlack/African AmericanChineseFilipinoGuamanian or ChamorroJapaneseKoreanNative HawaiinOther AsianOther Pacific IslanderSamoanVietnameseUnknownWhite
Ethnicity*

Another Hispanic, Latino/a, or Spanish OriginCubanMexican, Mexican American, or Chicano/aNon-Hispanic or Latino/aPuerto RicanUnknownOther or Undetermined
Tribal Affiliation and Employment
Enrolled in a tribe?

YesNo
Descendant?

YesNo
Name of Tribe
Tribal ID:
Country of Origin? *
Agricultural Worker?*

YesNo
Are you a veteran?*

YesNo
Employment Status*

UnemploymentSelf EmployedFull TimePart TimeRetiredOtherStudent
Employer
Occupation
Student Status*

Full TimePart TimeNot a Student
Responsible Party Information

If Patient is under 18
If patient is under 18, please check:

ParentGuardianFoster ParentSocial Worker
Parent/Guardian/Foster Parent Name(s):
Date of Birth (00/00/0000)
Social Security Number
Foster Care Case Worker's Name
Foster Care Case Worker's Number

Area CodePhone Number
County of Case
Email address:
Payment Information and Insurance
Please select your medical insurance carrier*

Medical AssistanceBlue Cross Blue ShieldCignaHealth PartnersMedica/United Health CareMedicarePreferred OneUCareI DO NOT have insuranceOther
Insurance ID Number:
Insurance Group Number:
Policy Holder Name:
Policy Holder's Date of Birth (00/00/0000)
Secondary Medical Insurance Name
Insurance ID Number
Insurance Group Number:
Policy Holder Name
Policy Holder's Date of Birth (00/00/0000)
Primary Dental Insurance Name:
Insurance ID Number:
Insurance Group Number:
Policy Holder Name:
Policy Holder's Date of Birth (00/00/0000):
Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Phone Type*

HomeWorkCellOther
Relationship:*

ParentSpouseChilcSiblingStep ParentOther
REGISTRATION/HIPAA CONSENT
- TO OUR PATIENTS: Before you begin treatment at Native American Community Clinic (NACC), the law requires that we explain your rights and responsibilities while a patient at NACC. If you have a complaint or concern about your care, please discuss it first with your care provider. If your concern remains unresolved, you may call the Clinic Manager at (612) 872-8086. Except in an emergency, NACC reserves the right to decline care if this form is not signed. You have the right to revoke this consent at any time. This consent expires in one year. Please read and check the appropriate paragraphs and sign the form below. Ask questions if you do not understand it.
- *CONSENT TO ACCESS MEDICATION HISTORY: I understand that NACC gets information about any medications prescribed to me from a database so that your medical information is accurate.
- CONSENT FOR TREATMENT: By signing this form, I consent to and authorize my health care provider to examine and treat me. I understand that this could include lab tests, x-rays, education, or other diagnostic procedures. I understand that my provider is available to explain the purpose of procedures and treatments, and that I have the right to refuse the recommended treatments.Treatment provided face to face or via telehealth.
- PATIENT'S RIGHT TO PRIVACY PRACTICES/HIPAA: I acknowledge that, under the Health Insurance Portability &Accountability Act of 1996 ("HIPAA"). I have certain rights to privacy regarding my protected health/dental/mental health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the multiple healthcare/dental/mental health providers who may be involved in that treatment directly and indirectly; obtain payment from third party payers; conduct normal health/dental/mental health operations such as quality assessments and provider certifications. These are posted in the reception area. If I would like a copy of NACCs privacy form, I will ask for one. I understand that my health records will not be used for research without my permission as described in the Privacy Notice. However, for the purpose of improving NACC’s clinical services and program planning, my health data may be accessed by an evaluator of quality improvement and performance measures. At no time will my personal identity be connected to this information gathering.
- CONSENT TO SHARE INFORMATION WITHIN NACC: I understand that I am seeing a health care provider within NACC, and that NACC Medical, Dental and Counseling Clinics are linked by a computer database. This allows them to share confidential information, except for psychotherapy notes, within NACC clinics to provide me better care.
- RELEASE OF MEDICAL RECORDS FOR MY MEDICAL CARE OR AS REQUIRED BY LAW: I agree that a copy of my medical records, except for psychotherapy notes, may be sent to any of my physicians or healthcare providers. This includes release to any of the NACC Affiliates (such as Fairview University Health Care, Hennepin County Medical Center, Children's Hospital orAbbott Northwestern Hospital) for purposes of my medical care and for business operations. I also agree that NACC can release my medical records to accrediting or regulatory agencies if those agencies request my records as allowed by the law.
- INSURANCE/ MEDICARE/ MEDICAID - PAYMENT OF NACC MEDICAL BILLS: I consent to the disclosure of my protected health information for the purpose of payment, treatment, and health care operations. I request that payment of authorized benefits be made to the Native American Community Clinic on my behalf for any services furnished to me or my child by Native AmericanCommunity Clinic. I assign the benefits payable for physician services to the physician or organization furnishing the services. In consideration of clinic visits, I agree to pay Native American Community Clinic for all charges not covered by any third-party payor.
- CONSENT TO ACCESS MEDICATION HISTORY: I understand that NACC gets information about any medications prescribed tome from a database so that your medical information is accurate.
- SERVICES OR SUPPLIES: Native American Community Clinic may use other companies to help in the evaluation and treatment of myself or my child. If another company performs a service or provided equipment, they will bill your insurance. Native American Community Clinic cannot answer questions about bills received from other companies.
CARE COORDINATION: NACC has been certified by the Minnesota Department of Health as a Health Care Home (HCH) Clinic.Therefore, all patients with one or more chronic conditions are eligible for care coordination services which are voluntary and available tome unless I choose NOT to participate. I understand that my provider is available to explain this service and refer me to a CareCoordinator for follow-up.

I opt out of HCH
RESEARCH PARTICIPATION: I understand that NACC or an evaluation partner may invite me to participate in research to help us improve health and reduce disparities in our community. I am not required to participate.

I opt out of being contacted for research
Consent to treatment*

I consent to HIPAA / Registration section above
I have reviewed the patient responsibility and financial information sheet and will ask for a copy of my records if interested*

Yes, I have reviewed the patient responsibility and financial information sheet and will ask for a copy for my records if interested.
Consent for a health professional student: I understand that I may be asked to have a medical student or other health professional student involved in my care. I also understand that I may decline and that this declination will not affect my care or treatment. Students are always under direct supervision of a licensed healthcare professional*

AcceptOpt Out of Students
OTHER INDIVIDUALS AUTHORIZED TO CONSENT TO TREATMENT: In addition to legal guardians of the minor patient, the following person(s) is/are authorized to consent to recommend medical care for my child.
Please write name and relationship. Separate each person authorized to consent with a comma.
Please sign below to complete form
Patient/Legal Representative Signature*

Clear
Date*

MonthDayYear
Date
NACC Patient Income Survey

We are federally required to ask about every patient’s family income, regardless of your insurance status. Please complete the following information. Your information will be kept confidential.
1. Family Size (Number)*
2. Please fill in the amount of your family’s household income*
Income $
Income amount per:*

WeekMonthYear
Family Total Annual Income Range:*

$0-$11,490$11,491-$17,235$17,326-$20,108$20,109-$22,980$22,981-$27,144$27,145-$31,020$31,021-$35,610$35,611-$39,630$39,630+
Please fill in the Names and Dates of Birth for each person in the household below.

The information below is used only to enter your income in the appropriate screen in your family’s information in our system.
Person 1: Name

First NameLast Name
Person 1: Date of Birth

MonthDayYear
Date
Person 2: Name

First NameLast Name
Person 2: Date of Birth

MonthDayYear
Date
Person 3: Name

First NameLast Name
Person 3: Date of Birth

MonthDayYear
Date
Person 4: Name

First NameLast Name
Person 4: Date of Birth

MonthDayYear
Date
Person 5: Name

First NameLast Name
Person 5: Date of Birth

MonthDayYear
Date
Person 6: Name

First NameLast Name
Person 6: Date of Birth

MonthDayYear
Date
Person 7: Name

First NameLast Name
Person 7: Date of Birth

MonthDayYear
Date
Person 8: Name

First NameLast Name
Person 8: Date of Birth

MonthDayYear
Date
(No identifying information will be used for purpose of the financial report)

This information is used for annual reporting only
Date Time
Email
example@example.com
Should be Empty:

Native American Community Clinic

Additional Information

Tribal Affiliation and Employment

Responsible Party Information

Payment Information and Insurance

Emergency Contact Information

REGISTRATION/HIPAA CONSENT

Please sign below to complete form