Online Application

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

Emergency Contact

Name *

Relationship *

Phone # *

Are you a U.S. citizen? *

Yes No

EMPLOYMENT

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 *

Max file size: 20MB

DOCUMENT 6 *

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. *

O N L I N E A P P L I C A T I O N

PATIENT INFORMATION FORM