Amador Health Center 999 W. Amador Ave.

Suite A Las Cruces, NM 88005

(575) 527-5482

PATIENT INFORMATION

Last Name ________________________First Name _________________________Middle__________________ Social Security #________________________ Date of Birth_____________________________ Gender Identity Sexual Orientation

Female Straight or heterosexual

Male Bisexual

Female-to-Male transgender Don’t Know Male-to-Female transgender Choose not to Disclose

Choose not to disclose Lesbian, Gay, or Homosexual Additional Gender or other- please specify Something else, please describe

___________________________________ _____________________________________

Address_____________________________________________________________________________________ City State Zip Phone _________________ Emergency Contact ____________________________ Phone __________________

FILL ALL THAT APPLY

Race (check one) White African American Native American Other__________________________ Ethnicity (check one) Hispanic Non-Hispanic Homeless Status (check one) Doubling Up Not Homeless Shelter Street Transitional Migrant Worker (check one) Migrant Not A Farm Worker Seasonal Language (check one) English Spanish Other Veteran (check one) Yes No Disabled (check one) Yes No Primary Medical Coverage _________________________________________________ Primary Pharmacy ________________________________________________________

PATIENT (OR GUARDIAN) CONSENT FOR TREATMENT:

I authorize the Providers for St. Luke’s Health Care Clinic to examine, diagnose, and recommend treatment to me or person under my care. I agree to be the responsible party for the payment of all services performed at the Clinic that are not covered by my insurance. ASSIGNMENT OF BENEFITS TO PROVIDER: I authorize payment of medical benefits to the undersigned physician or supplier for services. I certify that the information provided on this form is correct to the best of my knowledge. X_________________________ Patient Signature ____________________________ Print Name of Patient ________________ ____________________________ Date Relationship

ST LUKE’S NO SHOW POLICY

St Luke’s works diligently to see all patients that come in to see a doctor. Because of that reason we will only allow 3 no-show no-calls.After that, appointments will not be made for you. You will be seen as walk-ins and may have a long wait. Please call us if you cannot make your appointment. 575-527-5482

I have read this policy and understand .

Signature _______________________________________Date_________________________

Print Name ______________________________________________

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HIPAA Compliance Program

FORM Us

AMADOR HEALTH CENTER 999 W. Amador

Las Cruces NM 88005 575-527-5482 Phone

575-525-3542 Fax

Notice of Privacy Practices and Patient Consent For Use and Disclosure of Protected Health Information

_________________________________________________ _________________ PATIENT NAME DATE

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain Patient Rights regarding my protected health information.

I understand that St Lukes Health Care Clinic dba AMADOR HEALTH CENTER may use or disclose my protected health information for treatment, payment or health care operations—which means for providing health care to me, the patient; handling billing and payment; and, taking care of other health care operations. Unless required by law, there will be no other uses and disclosures of this information without my authorization.

St Lukes Health Care Clinic has a detailed document called the ‘Notice of Privacy Practices’. It contains a more complete description of your rights to privacy and how we may use and disclose protected health information.

I understand that I have the right to read the ‘Notice’ before signing this agreement. If I ask, St Lukes Health Care Clinic will provide me with the most current Notice of Privacy Practices.

My signature below indicates that I have been given the chance to review such copy of the Notice of Privacy Practices. My signature means that I agree to allow St Lukes Health Care Clinic to use and disclose my protected health information to carry out treatment, payment, and health care operations. I have the right to revoke this consent in writing at any time, except to the extent that St Lukes Health Care clinic has taken action relying on this consent.

___________________________________________________ ________________ SIGNATURE (Patient or Legal Custodian/Authorized Representative) DATE ___________________________________________________ ________________ Relationship to Patient if signed by another party DATE You may obtain a copy of our Notice of Privacy Practices, including any revisions of our ‘Notice’ at any time by contacting: St Lukes Health Care Clinic dba AMADOR HEALTH CENTER 999 W. Amador, Las Cruces NM 88005 575-527-5482 Phone, 575-525-3542 Fax.

999 W. Amador Ave., Las Cruces, NM 88005 (575) 527-5482 Voice 575-652-4243 Fax

DECLARATION OF INCOME STATEMENT/(DECLARACION DE INGRESOS)

I, ___________________________________________do hereby declare on (date)___________that: (Yo) (Applicant’s Name/Nombre del Solicitante) (declaro que en esta fecha) (date) My household consists of _______ persons and the following household members: (En mi hogar viven ________personas: ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ My household’s gross income, for all household members 18 years and older, for the 30 day period prior to the date of the application for assistance is (El total de los ingresos de mi hogar durante los últimos 30 días antes de la fecha de esta aplicación es de $__________.______ ________________________________________________________________________________ I have documented proof and will be providing the following: ___Federal Income tax return ( Ingresos de Federal) ___One month’s worth of check stubs (Un mes de talons de cheques) ___Letter from employer (Carta de empleo) _____________________________________________________________________________________ I have no documented proof of income at this time due to the following: (No tengo documentación que compruebe mis ingresos por la siguiente razón:) ___Homelessness (Si hogar) ___Have zero income (No tengo dinero) ___Get paid cash ( Me pagan en efectivo)

I certify that the above information for the income is true and correct to the best of my ability. (Certifico que la información de ingresos proveída es verdadera y correcta según mi saber y entendimiento.) I understand that the information will be verified to the fullest extent possible. (Comprendo que la informacion proveida en esta aplicacion sera verficada hasta donde sea.

_X_______________________________________________________________________ _____________________ Signature / Firma Date / Fecha

________________________________________________________________________ _____________________ Witness/Testigo Date/Fecha

Staff Reviewed by Date

____________________________________________________________________________ _____________________

Medical History Questionnaire Name: ______________________ Date of Birth: ____/____/_____

Allergies?/¿Alergias? □ Yes/Si □ No If Yes, list all allergies/Si es así, enumere todas las alergias. ____________________________________________________________________________________________

Medications?/¿Medicaciónes? □ Yes/Si □ No If yes, list all medications/Si es así, liste todos los medicamentos. ____________________________________________________________________________________________ Past Medical History/Historial Medico List all medical history/Enumerar todos los antecedentes medicos ____________________________________________________________________________________________ Past Surgical History/Antecedentes quirúrgicos pasado List all surgeries/Listar todas las cirugías ___________________________________________________________ Family History/Antecedences Familiars Relation/Relacion _____________________________________________________________________

□ Alcoholism/Alcoholismo □ Arthritis/Artritis □ Depression/Depresion □ Cancer □ Diabetes

□ Genetic Disease/Enfermedad Genetica □ Heart Disease/Enfermedad del Corazon Problem/Problema: ___________________________________________________________________ Social History/Historia Social Occupation/Ocupación _________________________________________________________________

Employment/Empleo □ Full-time/Tiempo Complete □ Part-time/Tiempo Parcial

□ Retired/Jubilado □ Unemployed/Desempleado

□ Not working due to WC injury/No trabajo debido a una lesion WC Family/Familia

Marital Status □ Single/Solder □ Married/Casado □ Divorced/divorciado □ Widowed/Viudo Number of Children/Numero de hijos: ______________________________________________________________ Type of exercise/Hace ejercicio: __________________________________________________________________

Papsmear/Papanicolaou □ Yes/Si □ No

Colonoscopy/Colonoscopia □ Yes/Si □ No

Prostate Cancer Screening/Prueba de deteccion de cancer de prostate □ Yes/Si □ No Use of Drugs, Alcohol, Tobacco/ Uso de Drogas, Alcohol, Tabaco

Do you drink alcohol?/¿Bebes alcohol? □ Yes/Si □ No

Do you smoke tobacco?/¿Fumas tabaco? □ Yes/Si □ No

Do you drink caffeine?/¿Tomas cafeína? □ Yes/Si □ No

Do you use illegal drugs?/¿Usas drogas ilegales? □ Yes/Si □ No

Have you had a Tetanus shot?/¿Ha tenido una vacuna contra el Tétanos? □ Yes/ Sí □ No If Yes, how long ago?/Si es así, ¿hace cuánto tiempo? ________________________________________________

Office Use Only: Appt Time: Walk-In WC FP UC □ SELF PAY HT: WT: Temp: B/P: R: P: O2:

999 W. Amador Ave. Suite D • Las Cruces, NM 88005 (575) 556-9681 OFFICE • (575) 395-6953 MOBILE HELPLINE

BEHAVIORAL HEALTH SELF REFFERAL You may want to call the HELPLINE to talk confidentially with one of our counselors or case managers about your answers to questions or concerns below. You may complete your registration with our Health Center before your first clinic visit. You are always welcomed to visit us to discuss your healthcare needs. Reasons for Visit PRESENT PSYCHOLOGICAL/EMOTIONAL PROBLEMS: History of experience or witnessing recent trauma (sexual or physical abuse/assault, violence, accidents, war, natural disaster, death) Not sleeping well Feeling depressed, sad Feeling stressed, nervous, anxious Feeling lonely, isolated Bothered by thoughts, impulses or images you cannot get rid of or control Hard to concentrate or focus Thinking too much about certain situations, worrying excessively about things or specific items Negative thinking, irrational beliefs Suicidal thoughts or thoughts about harming others Hearing voices or having visions others cannot perceive SUBSTANCE USE PROBLEMS: Drinking alcohol (beer, wine, liquor) too often Consuming too much alcohol when drink Experiencing alcohol withdrawal symptoms when trying to drink less or stop drinking DWI arrests Using illicit opiates like heroin Using prescribed opioids (painkillers…Vicodin, OyxContin, methadone) for non-medical reasons Using benzodiazepines like Valium, Xanax, or Ativan for non-medical reasons Using stimulants like methamphetamines or crystal meth for recreational purposes Smoking or using tobacco products MEDICATION MANAGEMENT: Refill existing prescriptions or seek a medication change Have you received these medications before? If so, where? Do you have had a recent history of therapy for behavioral health or substance use? If so, where? For Your First Visit: If you do not have any of these documents, we may still be able offer services 1.Come 15 minutes early to process paperwork. 2. Bring your insurance, Medicare or Medicaid Centennial Care card. 3. Bring financial information (current tax return or copies of pay stubs) if applying for discount fee programs. 4. Bring any medications you are taking. 5. Bring immunization records. 6. Bring information about any medical care you have received elsewhere recently. 7. Bring a valid photo ID.