Please list all children under 18 years of age who are Alliance Community Healthcare’s patients:
ASSIGNMENT OF BENEFITS: I authorize payment of medical benefits to be sent directly to Alliance Community Healthcare, Inc., or its individual providers for services rendered for me and all my identified children under 18 years of age as listed above.
FINANCIAL AGREEMENT: I understand and agree that I am ultimately responsible for the balance for myself and all my identified children under 18 years of age as listed above for any professional services rendered. Should my insurance claim be denied for lack of eligibility or termination of coverage, I understand that I will be held responsible and intend to make payment for any balance due in those instances.
AUTHORIZATION OF TREATMENT: I hereby give permission to the staff of the Alliance Community Healthcare, Inc., to provide medical and dental treatment, vaccine administration, emergency treatment and/or other services. Routine testing for HIV (Human Immunodeficiency Virus), HCV (Hepatitis C) and/or HBV (Hepatitis B) will be performed. I authorize access to prescription information from Sure Scripts and/or release medical information for reimbursement purposes for myself and all my identified children under 18 years of age as listed above. I have received a copy of the PATIENT BILL OF RIGHTS, 24 HOUR ON-CALL POLICY, HEALTH CARE PROXY, LIVING WILL, PAIN MANAGEMENT, AND HIPAA NOTIFICATION
I am not interested in disclosing my financial information; therefore, my family and I are not eligible for the sliding fee discount program.Attached is my income documentation – tax records, pay stubs, employer letter, etc. (Please see attached Sliding Fee Application)I have no documentation to verify my income. (Please see attached Self-Declaration)
Completion of this consent is necessary to offer services to a patient. Some items may not apply to your current visit, however in order to provide comprehensive care during this visit and future visits we request that you complete this content entirely.
I acknowledge that Alliance Community Healthcare has provided me with its Notice of HIPAA Joint Privacy and my Patient Bill of Rights in accordance with the NJ State Law.
The purpose of this financial agreement is to help Alliance patients understand about medical/dental insurance, eligibility, coverage, and our office policy and services.
It must be understood that:
The patient or Patient’s Legal representatives hereby acknowledge that he/she is eligible for Health/Dental Insurance Benefits and Coverage/ That in the event of ineligibility for coverage of plan benefits, as well as non-authorized procedures and non-covered services. He/she understands and agrees to be fully financially responsible for payment of all costs incurred during the delivery of services and agrees to pay all charges to Alliance Community Healthcare.
To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their visit on time. If it is necessary to reschedule the appointment, please call us immediately at (201) 451-6300.
A reminder call to you is made/attempted the day prior to your scheduled appointment.
A minimum of 24 hours cancellation notice is required for appointments. If you do not cancel in advance, and do not present to the office for your appointment, this will be considered a “No-Show: appointment.
If you incur 3 “No-Show/Missed” appointments within one year, you will be charged a $25.00 fee and no longer will you be able to schedule appointments in advance without a $25.00 pre-payment for the visit.
We value you as a patient and will do everything we can to accommodate you, so that you don’t incur any no show charge please be courteous and call if you are unable to keep your scheduled appointment.
Our goal is to provide quality medical care in a timely manner. In order to do so we have had to implement an appointment/cancellation policy. The policy enables us to better utilize available appointments for our patients in need of medical care.
I have read and understand the Alliance Community Healthcare No-Show/Missed appointment Policy.
A written statement of a person’s wishes regarding medical treatment- this often includes a living well, made to ensure the patient’s wishes are carried out if the patient is unable to communicate them to a doctor.
being of sound mind, willfully and voluntarily designate the following person as my health care representative to make any and all health care decision for me in the event that I become incapable of making decisions for myself. With this designation, I trust that this person will act in my best interest and in accord with my wishes.
If the person I have named above is unable to act as my health care representative, I hereby designate the following person(s) to do so:
If you are not completing an Instruction Directive/Living Will, please go to Part III (Signature and Witnesses) in this form.
For more information regarding Advance Directives, please contact the Patient Services Manager.
The following health care instructions directive exercises my right to make decisions concerning my health care. This directive is intended to provide clear and convincing evidence of my wishes to be followed in the event that I lack the capacity to make or communicate my treatment decisions.
being of sound mind, willfully and voluntarily make known my wishes regarding my health care in the event that I can no longer make or communicate my decisions.
If my health condition, as determined by my attending physician and at least one additional physician, fits nay of the following criteria:
If I become permanently unconscious, If I have a terminal illness, If the life-sustaining treatment is experimental and not proven therapy or If I have a serious irreversible condition and the likely risks and burdens associated with the treatment would outweigh the likely benefits; or unwanted medical intervention would be inhumane, all the following statements are consistent with my wishes:
(Please check all that apply)
I do wantI do not want - Cardiac resuscitation.
I do wantI do not want - Mechanical respiration.
I do wantI do not want - Blood or blood products.
I do wantI do not want - Kidney dialysis
I do wantI do not want - Antibiotics.
I do wantI do not want - Chemotherapy/radiation therapy.
I do wantIdo not want - Simple diagnostic tests (blood work/x-rays).
I do wantI do not want - Artificial or invasive forms of nutrition.
I do wantI do not want - Artificial or invasive forms of hydration.
I do wantI do not want - To make an anatomical gift of all or part of my body.
If yes, specify: All organsOnly some organs
Only this organs:
I also direct that I be given all medically appropriate care necessary, including pain medications, to make me comfortable and to maintain my personal hygiene and dignity, even if they dull consciousness and indirectly shorten my life.
By accepting this section, I indicate that I understand and agree with the contents of this document.
SLIDING FEE OPTOUT
I do not want the sliding fee
Qualifications for the sliding scale fee discount program are based on gross annual income and family size compared to the federal poverty levels. You are required to provide ACH with proof of income and a complete application prior to your second visit. If documentation is not provided by the second visits, the patient will be considered 100% self-pay. You must verify your income and family size at least annually or notify when changes occur if sooner. Payment of your nominal amount of flat rate is expected at the time of service. See ACH SFDP policy. The acceptable forms of proof of income are:
Please note that the federal poverty levels change annually which may impact your eligibility for the sliding scale fee discounted program.
Income will be defined as ALL sources and forms of revenue/earnings/funds (before taxes/gross/total income, e.g. line 22 of Form 1040/line 15 of Form 1040A/adjusted gross income line 4 of 1040EZ and Line 7 for 2018 redesigned 1040 (adjusted gross income or AGI)) (For Tax Year 2018, you will no longer use Form 1040A or Form 1040EZ) earned or received by an individual or family. Examples of income include but are not limited to: self-employment earning (net of business expenses), unemployment, gross employment earnings, tips, child support, alimony, interest, dividend, retirement/pension or social security income, student support income, welfare or other public assistance payments, veterans payments, survivor benefits, pension or retirement income, rental income, royalties, income from estate or trusts, educational assistance, assistance from outside the household, and other miscellaneous source, etc. Non cash benefits (such as food stamps and housing subsidies) do not count and income excludes capital gains or losses.
Family members who are considered for the eligibility criteria for Sliding fee program include the following individuals who live in the same household:
Do you have any type of insurance that will cover all or a portion of your medical expense?
If yes, please list below and provide copy of insurance card to ACH Staff.
I declare under penalty of perjury that the above information is true and correct, and I give Alliance Community Healthcare permission to investigate any information given in this application. I understand that this information will be kept in strict confidence. I also understand that if my income or “family size” should change, I am required to notify Alliance Community Healthcare on my next visit to the health center. All the members included above in your family size are automatically approved in ACH’s SFDP once you have been approved.
[It's mandatory to accept all the ACCEPTANCE clauses]
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Alliance Community Healthcare was founded in 1963. Today we deliver comprehensive healthcare services to more than 19,000 patients and handle more than 58,000 outpatient visits annually.
We offer primary care, women’s health, family care, dental services, pediatrics, and more.
Alliance Community Healthcare complies with applicable Federal Civil Rights Laws and does not discriminate or exclude people on the basis of race, color, national origin, age, disability or sex.
Read the complete statement.