Chesapeake Care Clinic
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O N L I N E A P P L I C A T I O N
PATIENT INFORMATION FORM
PERSONAL INFORMATION
*
Indicates required field
Last Name
*
First Name
*
Middle Name
*
Suffix
*
Gender
*
Male
Female
Date of Birth
*
Social Security Number
*
Street Address
*
Apt/Lot #
*
City
*
State
*
Zip
*
Home Phone #
*
Cell Phone #
*
Consent to Text
*
Yes
No
Work Phone #
*
Email
*
Best Phone # and Time to Contact You
*
Primary Language Spoken
*
Race
*
Hispanic/Latino
*
Yes
No
Marital Status
*
Married
Single
Divorced
Separated
Widowed
Emergency Contact
Name
*
Relationship
*
Phone #
*
How did you hear about our clinic?
*
Friend/Family
Doctor/Hospital
Internet Search/Website
Flyer/Handout
Current Patient
TV
Other
Are you a U.S. citizen?
*
Yes
No
EMPLOYMENT
Employment Status
*
Unemployed
Full-Time
Part-Time
Retired
Self-Employed
Student
Employer's Name
*
Employer's Phone #
*
Employer's Complete Address
*
INSURANCE INFORMATION
Medical Insurance Information
Do you have any health insurance, Medicare, or Medicaid? (If yes, you are NOT eligible for medical services)
*
Yes
No
Insurance Name
*
Policy Holder Name
*
Policy or Member Number
*
Dental Insurance Information
Do you have dental insurance? (If yes, you are NOT eligible for any services)
*
Yes
No
Insurance Name
*
Policy Holder Name
*
Policy or Member Number
*
OTHER INFORMATION
Do you have a vision plan? (If yes, you are NOT eligible for medical)
*
Yes
No
Have you served in the US military?
*
Yes
No
Do you receive disability?
*
Yes
No
If yes, what kind and when did it start?
*
Did you file a tax return for 2021?
*
Yes
No
Does someone claim you as a dependent?
*
Yes
No
If yes, who claims you?
*
DOCUMENTS TO UPLOAD
Photo ID (driver's license, permanent resident card, or passport)
*
Max file size: 20MB
Current Utility Bill/Lease in Patient's Name with Current Address
*
Max file size: 20MB
Federal Taxes Form 1040
*
Max file size: 20MB
Social Security/TIN Card
*
Max file size: 20MB
Insurance Card
*
Max file size: 20MB
PLEASE UPLOAD
ALL
OF THE FOLLOWING DOCUMENTS THAT APPLY TO YOU:
Business Taxes for the Most Recent Tax Year
Latest Quarterly Filing
90 Days of Business Bank Statements
Business Profit/Loss Statement for Current Year
60 Days of Most Recent Pay Stubs
Social Security or Supplement Security Income Award Letter
Veteran Benefits Award Letter
Pension or Retirement Award Letter or Statement
Unemployment Award Letter
Verification of Alimony
Verification of Child Support
Workers Compensation Award Letter
SNAP Letter
TANF or Transitional TANF Assistance
Housing Assistance Letter
Owned Rental or Investment Property Documentation
Stocks, Bonds, CDs, 401K Statements
90 Days of Most Recent Bank Statements for each Account Owned
Verification of Support Form
DOCUMENT 1
*
Max file size: 20MB
DOCUMENT 2
*
Max file size: 20MB
DOCUMENT 3
*
Max file size: 20MB
DOCUMENT 4
*
Max file size: 20MB
DOCUMENT 5
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Max file size: 20MB
DOCUMENT 6
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Max file size: 20MB
DOCUMENT 7
*
Max file size: 20MB
DOCUMENT 8
*
Max file size: 20MB
DOCUMENT 9
*
Max file size: 20MB
DOCUMENT 10
*
Max file size: 20MB
DOCUMENT 11
*
Max file size: 20MB
DOCUMENT 12
*
Max file size: 20MB
CONSENT
*
By checking the boxes below I agree to comply with the terms of eligibility as set forth & outlined by Chesapeake Care Clinic in these statements.
TELEHEALTH CONSENT
*
I, being physically located in Virginia, hereby consent to engaging in telehealth with Chesapeake Care Clinic as part of my medical treatment. I understand “telehealth” means the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand telehealth involves the communication of my medical information both orally & visually to a health care provider at Chesapeake Care Clinic located in Virginia. I understand I have the following rights with respect to telehealth: (1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. (2) The laws that protect the confidentiality of my medical information also apply to telehealth. I understand the audiovisual information transmitted electronically will be encrypted during transmit & will not be stored. I also understand the dissemination of any personally identifiable images or information from the telehealth interaction to researchers or other entities shall not occur without my consent. I understand the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory & permissive exceptions to confidentiality, including, but not limited to reporting child, elder, & dependent adult abuse; expressed threats of violence towards an ascertainable victim; & where I make my mental or emotional state an issue in a legal proceeding. (3) I understand there are benefits, risks & alternatives involved with telehealth. Benefits include having access to medical care without having to travel outside of my local community. A potential risk of telehealth is because of my specific medical conditions, or due to technical problems, a face-to-face consultation still may be necessary after the telehealth appointment. Despite reasonable efforts on the part of my physician, the transmission of my medical information could be disrupted or distorted by technical failures. In rare circumstances, security protocols could fail causing a breach of patient privacy. (4) I understand telehealth based services & care may not be as complete as face-to-face services. I also understand if my physician believes I would be better served by another form of services (for example face-to-face services) I will be referred to a physician who can provide such services in my area. (5) I understand I may benefit from telehealth, but the results cannot be guaranteed or assured. (6) I understand I have a right to access my medical information & copies of my medical records in accordance with Virginia law.
CONSENT OF TREATMENT
*
I hereby authorize the health care providers & staff working at Chesapeake Care Clinic to examine &/or treat me. I realize that most of the health care providers are volunteers & are not being paid for providing professional services.
RELEASE OF INFORMATION
*
I authorize Chesapeake Care Clinic to both release & request information to/from any physician or other health care professional involved in my treatment. I further authorize release of information to any health care facility to which I may be discharged or transferred for treatment.
NOTICE OF PRIVACY PRACTICES
*
Chesapeake Care Clinic's Notice of Privacy Practices provides information about how we may use & disclose protected health information about you. The document is available to review online or at Chesapeake Care Clinic. I acknowledge that I have read the Notice of Privacy Practices from Chesapeake Care Clinic.
CONSENT FOR BLOOD TESTING
*
I understand Virginia State law states that when a health care worker is exposed to the body fluids of another person, the patient shall be deemed to have consented to testing & to the release of the results to the exposed person.
By typing my name, I certify that the information provided in my application is accurate & true to the best of my knowledge & belief. I understand that this information may need to be verified & that withholding information or giving false information will make me ineligible for care at the Clinic. I do not have prescription drug coverage & authorize representatives of Chesapeake Care Clinic to share medical & financial information with Rx Partnership & pharmaceutical companies (or their designees) as required for eligibility verification & audit purposes. I understand that to remain eligible for the Clinic's services, I must provide updated information annually. I will notify the Chesapeake Care Clinic of any changes to my income, household size, or insurance status.
*
Submit
HOME
OUR CLINIC
About Us
Board of Directors
>
Board Access
Patient Testimonies
Contributors
Videos
DONATE
Give Now
Donations
PATIENTS
New Patients
Services
Veterans Dental Program
Mini-Mission of Mercy
Eligibility Criteria
Online Application
Upload Documents
Online Payment
Privacy Practices
VOLUNTEER
Volunteer Opportunities
Volunteer Application
FUNDRAISERS
Wine Tasting
Taste of Chesapeake
Run For the Health of It
NEWS & RESOURCES
Annual Report
Newsletter Sign Up
Newsletter Archive
Facebook
CONTACT US
Contact Us
Hours of Operation
Location