New Patient FCCH Registration Form (English - Medical & BH) Logo

  • Patient Registration Form

    Please fill in the form below

  • Para completar este formulario en español:
    Versión en español

  •  - -

  • Patient Supplemental Information

  • Responsible Party Information

    The responsible party is the person or entity responsible for the payment for services.
  •  - -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Medical Insurance Information

  •  - -
  •  - -

  • If you are uninsured or if your insurance does not pay for some/all of the First Choice Services you receive, you maybe eligible for a sliding fee discount based on your household size and income.

  • As a Federally Qualified Health Center (FQHC) system, FCCH is required to offer a sliding fee discount for our patients who are unable to pay the full charges for care. First Choice receives grant money to assist those of our patients who qualify for a discounted fee for office visits and most procedures performed in our facilities. Depending on a patient’s family size and income, patients may qualify to receive services at a reduced rate. Income grids are updated every year, according to federal guidelines.

    Proof of income is required for all patients who do not have insurance and who want to apply for the sliding fee discount program to possibly get a reduced charge for the services they receive. However, all patients will be asked if they would like to provide proof of income for the discount, even if they have private insurance; many times, a patient’s insurance deductibles are very high or their insurance may not pay for all services provided. After the insurance company pays and if the patient qualifies for the discount by providing income documentation, FCCH/Central Billing can apply the discount to the patient’s balance. Discounts cannot be applied after the fact: current income documentation must be in place for the date of service for which a discount is sought.

    This is a federal government program and if any of the above data is false it may lead to being denied future slide (discount) options. First Choice can assist our patients with application for Medicaid and/or other health insurance or healthcare funding programs. If you would like to apply, please ask us to help!

  • Sliding Fee Documentation Process
    All patients seeking consideration for sliding fee discounts must provide documentation. Without one of the following forms of documentation, uninsured patients will be expected to pay at least the nominal visit fee at the time of service and will be billed for the remainder of the full charges, with no discount applied.
           

               If a first visit with us and you are unable to provide any proof of income for this date of service, First Choice can offer the One Time Affidavit, which would allow a personal attestation as proof of income for a sliding fee discount. The One Time Affidavit will ONLY be valid for ONE DAY, and will not be renewed at any other point throughout your care with us.
             

           For one (1) year of sliding fee eligibility, any one of the following “official” income documentation examples is considered acceptable; please note that documentation is needed from all household members who contribute to the household income:

    • A tax return with W-2 and/or 1099s from the prior year; total gross income is used to calculate income (Note: After April 15 of the current year, the return MUST be for the year that just ended.)
    • Check stubs for the prior month (Note: if paid weekly, requires 4 consecutive stubs; if paid bi-weekly, requires 2 stubs; monthly, just one) – gross wages are used calculate income
    • A signed employer statement (on company letterhead), confirming (gross) wages and frequency of pay
    • Check stubs, bank statements (for auto-deposits) or an authorized letter reflecting participation in/specified compensation benefits from a recognized benefits program (SSI, Social Security, VA or other pension, unemployment benefits, etc.)
    • If you are not employed and support is being provided by someone else, please request the separate form “Letter of Financial Support”, which must be completed, signed and notarized, and returned. 

     

  • I hereby certify for the purpose of visit to First Choice Community Healthcare that my present family income from all sources is $  * and I get paid    *   (frequency) with    * in my household supported by this income. I understand that this application is for a sliding fee discount of my charges. This is a federal government program and if any of the above data is false it may lead to being denied future slide (discount) options.

  • FIRST CHOICE COMMUNITY HEALTHCARE, INC. CONSENT TO ACCESS ELECTRONIC MEDICAL RECORDS


    All medical records are confidential under state and federal law. First Choice Community Healthcare (FCCH) must get your written consent to access any of your health information in order to provide your health care. This includes information which may be stored electronically by health care providers with which FCCH partners.


    By selecting, you give your permission for FCCH to electronically access any and all medical information from other providers and organizations, and to disclose your medical information electronically if another provider to whom you have given your permission requests it from FCCH for the purposes of coordination and continuity of care. This information may be accessed in one of two ways: either directly from the other provider; or through the New Mexico Health Information Collaborative (NMHIC). Once accessed, this information will continue to be protected by state and federal privacy laws, rules and regulations.


    This consent will remain in effect until you revoke it. Such revocation however will not apply to FCCH’s electronic patient record systems and associated interfaces necessary for the delivery of your care. You may revoke this consent at any time by contacting FCCH and requesting a revocation form. You may also opt out of having your electronic medical information available through the NMHIC by completing an Opt Out Form, available at www.nmhic.org. Your FCCH revocation will be effective from the date you sign the revocation but will not affect information obtained prior to your completion of the revocation. Your NMHIC Opt Out request may take up to 30 days once received by the NMHIC.
    If you do not provide your consent, FCCH will not be able to access medical records from other providers or facilities or through the Health Information Exchange.


    THERE IS NO PENALTY IF YOU DO NOT GIVE YOUR PERMISSION TO ACCESS YOUR ELECTRONIC MEDICAL INFORMATION OR IF YOU CHANGE YOUR MIND AT A LATER DATE.

    By selecting, I consent to allow First Choice Community Healthcare to access my electronic health information. I understand I may get a copy of this consent form and of my health information being shared.

     

     

  • CONSENT FOR TREATMENT AND RELEASE OF INFORMATION

    I consent to all health care services performed by First Choice Community Healthcare (FCCH), its employees, agents and affiliates, to include evaluation, diagnostic procedures, behavioral health, medical and dental treatment, as deemed necessary and appropriate by FCCH. I am aware of, and shall comply with, applicable FCCH policies as they relate to me as a patient of FCCH. I have been informed regarding FCCH Patient’s Bill of Rights and Responsibilities. Except as required by law or as otherwise described in this document and FCCH Notice of Privacy Practices, FCCH will not release my health information without my or my representative's valid written authorization. FCCH may share such information to carry out treatment, payment, or health care operations as described in the Notice of Privacy Practices.


    I agree to advise my provider of any medications I am taking, of other providers I may be seeing, and of any sensitivities or allergies I may have to any medications. I agree to provide my health information to my provider and to FCCH staff recording that information in my patient record. Continued treatment will include updating my health information at least once a year. I understand it may be necessary to release my health information to other providers for my treatment and care.


    I authorize FCCH to release my medical, behavioral, dental and/or billing records to individuals and entities as specified in the Notice of Privacy Practices and/or by federal and state law including health information which may be released to other health care providers who may be involved in my care. I understand that this authorization will remain in effect unless I revoke it in writing. Any revocation will affect disclosures necessary for payment for care provided to me by FCCH. This consent is separate from my written consent to release electronic health records which may be maintained by FCCH.


    I will pay for all charges for services I or my dependent(s) receive and which are not paid for through a third -party payer including deductibles, co-insurance, co-payment or non-covered charges. Co-payments and past due balances are due at the time of appointment check-in, unless previous arrangements have been made. Payment must be in the form of cash, check or credit/debit card. Returned checks are subject to standard bank fees, payable by cash or money order only, in addition to the amount of the returned check.

    Payment for Services: if you would like to apply for our sliding fee discount to help cover some of your out-of-pocket costs, we will need you to provide us certain financial information. The nominal fee for uninsured patients who qualify may vary by service type, and the percentage of total charges for a visit that are the patient’s responsibility to pay depends on family size and income. Your final bill for your visit may vary, according to the services you receive.


    I authorize FCCH to release any part of my/my dependent's health records to any third-party payer, their agent or legal representative, as required for payment of my/my dependent's medical bills. I have the right to refuse this release if I assume full financial responsibility for any services provided. I appoint FCCH as my attorney-in-fact to collect any insurance benefits to which I/my dependent(s) may be entitled from any third-party payer, up to the amount of the charges for the services rendered.


    I certify that the information I have given in applying for payment under Title XVII of the Social Security Act (Medicare) is correct. I consent to the release of my health information to the Social Security Administration and the Centers for Medicare and Medicaid Services, its intermediaries or carriers. I authorize that payment be made on my or my dependent's behalf to FCCH.

    I consent to receive notifications from FCCH for my protected healthcare and other services at the phone number provided, including my wireless number provided. I understand I may be charged for such calls by my wireless carrier and that such calls may be generated by an automated dialing system.

  • About Our Notice of Privacy Practices

    We are committed to protecting your personal health information in compliance with the law. The attached Notice of Privacy Practices states:


    • Our obligations under the law with respect to your personal health information.

    • How we may use and disclose the health information that we keep about you.

    • Your rights relating to your personal health information.

    • Our rights to change our Notice of Privacy Practices.

    • How to file a complaint if you believe your privacy rights have been violated.

    • The conditions that apply to uses and disclosures not described in this Notice.

    • The person to contact for further information about our privacy practices.

    We are required by law to make available to you a copy of this Notice and to obtain your acknowledgement that you have reviewed and/or received a copy of this Notice.

  • Clear
  • Should be Empty: