New Patient Registration Form

New Patient Registration Form
Damien Center – One Home

We’re glad you’ve chosen Damien Center for your care.

At Damien Center, we operate as a Patient-Centered Medical Home (PCMH). This means your care is built around you—with a team working together to provide safe, high-quality, and coordinated care focused on your needs.

What This Means for You
- You will have a care team that works together to support your health
- We focus on easy access to care, including same-day appointments when needed
- We coordinate your care across services like medical, behavioral health, dental, and more
- We work with you to make decisions about your care—your voice matters
Choosing Your Primary Care Provider (PCP)

As part of our care model, you will choose a Primary Care Provider (PCP).

Your PCP is:
- Your main healthcare provider
- The person who gets to know you and your health history
- The provider who helps coordinate all of your care
Patients are encouraged to choose a PCP when scheduling their first appointment, and you can select someone who best fits your preferences (such as availability, language, or personal needs).

Why Choosing a PCP Is Important

Having a PCP helps ensure:
- Continuity of care – seeing the same provider builds a stronger relationship
- Better coordination – your PCP helps manage referrals, medications, and follow-up care
- Improved health outcomes – consistent care helps us better understand and support your health needs
Our goal is for most of your visits to be with your PCP so you receive consistent, personalized care.

You’re in Control
- You can change your PCP at any time
- If you need care quickly, we will still help you get the soonest available appointment
- Our team will always support you in choosing or updating your provider
If you have questions or would like help choosing a provider, our team is here to help. We’re excited to partner with you in your care.
Welcome to the Damien Center!

To register, please complete this form. If you need help, ask the front desk or call 317.632.0123.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
What is your primary language:
Please enter your primary language.
Are you deaf or hard of hearing?
Do you need an interpreter?
What is your Date of Birth?

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Age
Please note that our services are currently available only to patients aged 16 years and older.

This policy is in place to ensure we provide the most appropriate care and support within our current capabilities. If you have questions or need assistance finding services for patients under 16, please don’t hesitate to contact our team.

Parent/Guardian Consent
Patient’s under the age of 18 require a Parent/Guardian consent.The Parent/Guardian must be present at the first patient appointment and present with a photo ID that matches the ID on this registration form.

Please note: Immunizations, Procedures, and Diagnostic Imaging will NOT be rendered without a Parent/Guardian present at any appointment.

Parent/Guardian must complete the rest of this registration packet.
First Name
Parent/Guardian's First Name
Last Name
Parent/Guardian's Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearParent/Guardian's Date of Birth
Gender:
Mailing Address:

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian's relationship to the patient:
Example: Mother, Father, Aunt, Uncle, Foster Parent...
Phone Number
Please enter a valid phone number for the Parent/Guardian.Format: (000) 000-0000.
Parent/Guardian's Email Address:
example@example.com
Please take a picture of the front of the Parent/Guardian's State ID or Driver's License.
Parent/Guardian's Signature:

By signing here, I am attesting that I am the Parent/Guardian and will complete the rest of the registration packet.

The Patient Portal/Healow
The most secure way to communicate with us is with our patient portal. We will need a non-work / non-school email to set up a patient portal account.
E-Mail Address:
Please select a reason below:
How would you like to get communication and appointment reminders? (select all that apply)
zzzWhat is your Date of Birth?

MonthDayYear

Household Size and Income
To comply with the Health Center Program requirements, we are required to collect information about income and household size from all patients to determine the patient’s income by the Federal Poverty Level. This information helps us determine how to best allocate resources and direct additional funding opportunities to help serve our patients.
What is your household gross income per year? (Income before taxes are taken out)
zzzHow many people (including yourself) live in your household?
How many people (including yourself) live in your household?

Health Center Sliding Fee Scale
This is a program that can assist you in paying any outstanding balance on your account. To apply for this program, you must provide verification of your income.

If you do not wish to participate in this program, please select, 'I do not wish to participate in this program'.

If you do not want to provide your income verification, please select, 'I refuse to provide my income verification'.

If you wish to apply for this program but do not have this information at the moment, please select, 'i Plan to apply for this program at a later time'.

If you would like to apply for this program now, please select, 'I want to apply now'.

You must provide income information for all members of your household. You may upload those documents below.

Proof of Income examples include:
- Most recent federal tax return
- 4506T - requests for transcript of tax return, verification of non-filing
- Thirty (30) days of pay stubs
- Other income which includes the following
- Social Security
- Public Assistance
- Retirement Pension
- Food Stamps
- Child Support
- Alimony
- Interest Income
- Other
Sliding Fee Scale
Income Verification

Cancelof

Patient Driver's License or State Identification Card
Take a photo of the front of the patient's Driver's License or State ID Card.
State and Insurance regulations require we verify identification before a provider can treat and/or issue a prescription.

Emergency Contact Information
zzzWhat name should we call your Emergency Contact?
What name should we call your Emergency Contact?

First NameLast Name
In an emergency, DC is allowed to contact and share your medical information with your emergency contact:
Relationship
Please include at least one contact phone number.
Cell Phone Number
Format: (000) 000-0000.
Home Number
Format: (000) 000-0000.

Payment and Insurance Information
If you do not have insurance, you must meet with an Insurance Enrollment Specialist. You may be able to get insurance or use our sliding fee scale. In order to apply, you must provide income information and your family size. Until we get your information, you are responsible for any cost.

If we do not take your insurance or you have an Health Maintenance Organization (HMO), we encourage you to choose an in-network provider who takes your insurance. Choosing to get your care with us means you are responsible for all charges.
Do you have health insurance?

Primary Insurance
Please take a photo of the front of your insurance card.
Please take a photo of the back of your insurance card.
Upload Image (if unable to take photo):
Primary Insurance Name:
Primary Insurance ID Number:
Primary Insurance Group Number:
zzzWho is the policy holder:
Secondary Insurance

Complete below if you are covered under multiple health insurance plans.
zzzWho is the policy holder:
Do you have a secondary insurance?

Secondary Insurance
Please take a photo of the front of your insurance card.
Please take a photo of the back of your insurance card.
Upload Image (if unable to take photo):

Cancelof
Secondary Insurance Name
Secondary Insurance ID Number
Secondary Insurance Group Number

Preferred Hospital

This information will be used when/if your provider orders a referral for you. Please note that preference may not be valid based on insurance requirements.
Do you and/or your insurance company have a hospital preference?
Preferred hospital's name:

Other
zzzIf yes, please input preferred hospital's name:

Preferred Pharmacy

Damien Center does have two pharmacies for your convienence!

26 North Arsenal Avenue (Holy Cross)

8902 East 38th Street (38th and Post Road)

Do you have a preferred pharmacy?
Please provide your preferred pharmacy.

Other, (Please enter name and address of Pharmacy)
Pharmacy Welcome Packet

The Damien Pharmacy Welcome Packet provides information on the services provided by Damien Pharmacy, contact information for the pharmacy, hours of operation and other helpful pharmacy-related information.

A copy of the Pharmacy Welcome Packet can also be obtained at the pharmacy.
Would you like a copy of the Pharmacy Welcome Packet sent to your email?
Please provide the email address where you'd like to receive your Pharmacy Welcome Packet.
example@example.com
Damien Pharmacy provides information (education) regarding your prescriptions utilizing a QR Code which can be scanned on any smart phone. If you prefer, the pharmacy can provide printed information regarding your prescriptions.
Would you like printed information provided with your prescriptions?
zzzIf yes, please provide your preferred local pharmacy.

Consents and Acknowledgement
- Damien Center will send you mail like billing statements, letters from your provider, or important safety information to the listed address below. We will only send you mail in plain white envelopes that display the sender as "DC". Our return address will be visible. We believe it is important to communicate with you, but we do value your privacy.
  
  Damien Center has permission to send me AGENCY ONLY mail that is directly related to its programs and services. Such mail may include letters regarding appointments, changes in services, policies and procedures, billing statements, and client satisfaction surveys.
  
  Damien Center has permission to share my name and address to government entities for HIV-SPECIFIC ONLY mail. Such mail may be from the Marion County Public Health Department’s HIV Services Program and/or the Indiana State Department ofHealth’s HIV Medical Services Program. Such mail may include letters regarding program eligibility, services, policies and procedures, and client surveys.
- In order for you to become a patient, we need your consent to provide you with care. We also need you to acknowledge that we provided you with certain important information and documents. If you have any questions about any of this information or need help completing this form, please do not hesitate to ask a member of our staff. It is important to us that you feel comfortable with all of this information. By signing, you are indicating that you understand the information, have been given a chance to ask questions, and are giving your consent.
  
  I understand that Damien Center is required by Indiana law to report all positive test results for human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS).
  
  I authorize release of medical record information, pursuant to applicable federal and state laws, rules, and regulations, to third party payors, insurance companies, health care institutions, health care providers, and other institutions. This may include records about infectious diseases, drug, and alcohol abuse. I understand that, once this information is released, it is no longer protected by Damien Center and may be disclosed by the party receiving the information. At any time, I may change my mind about agreeing to this release of information by providing written notice to Damien Center.
- Consent to Treat
  
  By signing this form, I authorize Damien Center to furnish such medical care services, including diagnostic tests, examinations, medical tests, procedures, blood tests, and mental health care to me that they deem appropriate for my health and well-being. I acknowledge that no representations, warranties, or guarantees as to results or cures have been made to me nor have I relied on any such representations, warranties, or guarantees. I understand that some of the individuals who will be involved in my care are not employees of Damien Center and that those individuals are not subject to the control and supervision of Damien Center.
- Mental Health Provider Disclosures
  
  I acknowledge that I have the right to inquire about my provider’s training and credentials as well as the reasonable risks and relative benefits of proposed treatments and alternative treatments that may be available to me.
  
  I understand that I have the right to withdraw consent for treatment at any time.
  
  Finally, I acknowledge that my provider has a “duty to warn” and limitations to confidentiality are waived should I disclose thoughts of harm to myself or any other person, as well as any abuse or neglect of vulnerable populations such as children or the elderly.
- Client and Visitor Code of Conduct
  
  To ensure Damien Center remains a safe, caring, and inclusive place, we ask that clients and visitors adhere to our Client and Visitor Code of Conduct:
  - Treat everyone with kindness, dignity, and respect. Offensive comments about race, religion, gender, sexual
    orientation, or personal traits are not acceptable.
  - Always use respectful and appropriate language and behavior. Some examples of language and behavior that
    will not be tolerated are:
    
    Verbal threats
    
    Suggestive or explicit words, phrases, gestures, or inappropriate sexual behavior
    
    Emotional abuse including attacks on a person's dignity, integrity, and competence
    
    Loud, obnoxious, and inappropriate conversations
    
    Touching another person without consent
    
    Abusive electronic or phone communication
  - Physical acts of violence or aggression including intimidation, harassment, sexual harassment and/or coercion as well as any behavior(s) that make other individuals or staff feel uncomfortable and/or unsafe will not be
    tolerated.
  - Throwing objects, tampering with and/or damaging property will not be tolerated.
  - Respect the property of Damien Center, staff, clients, and visitors. Theft will be prosecuted.
  - Avoid having phone conversations on speaker phone or streaming any video while in common areas.
  - Possession of weapons on the premises including guns, knives, or anything that can be classified as or used as a
    weapon is not allowed.
  - Brandishing weapons on the premises including guns, knives, or anything that can be classified as or used as a weapon will not be tolerated.
  - Only smoke or vape in the designated area outside.
  - Use or distribution of alcohol or illegal substances while on the premises is not allowed.
  - If you are bringing an animal, please respect the property and others’ fears or allergies.
  - There is no soliciting allowed on the property.
  - All clients and visitors will respect others’ privacy and avoid disrupting other clients’ care or experiences. Any
    behavior that impedes the providers and other staff members’ ability to meet with individuals and/or provide
    safe and effective care will not be tolerated.
  * Items in bold are considered threatening behavior and could result in immediate removal from the premises.
  
  Clients or visitors may be asked to leave and for severe violations could lose access to services or be restricted from future visitation.
  
  Our staff are committed to providing the highest levels of care. Please show them the respect they deserve and that you expect as a client or visitor. Thank you for choosing the Damien Center and joining us in our commitment to ensuring a safe, caring, and inclusive environment for us all.
- Informed Consent
  
  At Damien Center (DC), we are dedicated to ensuring the safety and well-being of our clients. As part of this commitment, it is our responsibility to inform you about the obligation of our staff to report under certain situations.
  
  We take your privacy and confidentiality seriously. Here’s how we keep your information secure:
  1. We do not disclose any identifying information without written consent, called a Release of Information (ROI), or Power of Attorney (POA).
  2. We comply with all HIPAA regulations and Privacy Practices and take active steps to prevent any breaches of confidentiality.
    There are some situations where we may be required to break confidentiality. Some of these exceptions include:
    
    Immediate Danger to Self or Others: If there is a clear and immediate threat of serious physical harm to yourself, such as a suicidal plan with means and intention, or to others such as assault or homicidal intention.
    
    Mandated Reporting Requirements: The law requires us to report certain incidents, such as:
    
    Suspicion of child abuse or neglect (physical or sexual abuse of any kind including trafficking)
    
    Suspicion of abuse or neglect of elder or endangered adults
    
    Dog bites
    
    Knife wounds
    
    Gunshot wounds
    
    Court Orders: If we are ordered by a court to release information.
  For more details, please refer to the Notice of Privacy Practices. HERE
  
  Duty to Report
  
  Mandatory Reporting: All staff members are legally required to report any suspected abuse or neglect of children, elder adults, or endangered adults. This includes physical, emotional, or sexual harm, as well as financial exploitation or neglect.
  
  Reasonable Suspicion: Reports are made based on reasonable suspicion or disclosure. If we believe that you or someone else may be a victim of abuse or neglect, we must report it to the appropriate authorities immediately. Reasonable suspicion can include but is not limited to:
  - Physical Signs: Unexplained bruises, burns, or injuries.
  - Behavioral Signs: Withdrawal, fearfulness, or aggressive behavior.
  - Verbal Disclosures: Statements from you or others indicating abuse or neglect.
  No Duty to Investigate: Our responsibility is to report, not to investigate. We do not verify the information or gather additional evidence. If there is reasonable suspicion to report, we are bound by law to do so.
  
  Duty to Warn: All staff members have a duty to warn if a client communicates an actual threat of harm to themselves or others. We are required to take reasonable steps to warn the potential victim or protect them from harm. Duty to Warn could be inclusive of involving law enforcement if necessary.
  
  HIPAA and Mandated Reporting / Duty to Warn:
  While the Health Insurance Portability and Accountability Act (HIPAA) generally protects your privacy, it allows for disclosures required by law. This means that mandatory reporting laws for child abuse, elder abuse, endangered adult abuse, duty to warn, and specific injuries such as gunshot or stab wounds override HIPAA protections.
  
  We appreciate your understanding of these important responsibilities. If you have any questions about this policy or need further information, please feel free to ask.
- Patient Rights and Responsibilities
  
  I have been given a copy of the Damien Center Rights and Responsibilities document and understand that both Damien Center and I are responsible for adhering to the Rights and Responsibilities. I understand that I have a right to file a complaint or grievance with Damien Center, as described on the Damien Center website and in the Patient Feedback notice posted on bulletin boards at the health center.
  
  Patient Bill of Rights: Click Here
- Financial Responsibility
  
  I understand that I am responsible for paying for all of the care I receive, and all of the charges incurred and, if insurance does not cover all of the cost, I am responsible for the remaining balance. I am responsible for knowing about my insurance coverage I have and for following all insurance policy rules. I authorize Damien Center to release my medical records and information to the extent necessary to obtain payment for the services provided and to receive all payments that I am entitled to under insurance policies. I know that if I do not pay what I owe, Damien Center may send the matter to a collection agency and/or attorney. I understand and agree to be responsible for reasonable attorneys’ fees, court costs, costs of collection, and interest.
  
  I am responsible for notifying Damien Center if my insurance changes at any time.
- Collection and Sharing of Client Information in CAREWare
  
  Agencies funded by the Indiana Department of Health "IDOH") HIV/STD/Viral Hepatitis Division and the Marion County Public Health Department ("MCPHD") to provide HIV counseling and testing, outreach, linkage to care, and care and treatment services are required to collect certain personal information. This information is entered and saved in a statewide database called CAREWare. CAREWare reports may be used for program evaluation and to meet funding requirements locally, statewide and federally, and any client information used will be done so without revealing names or other information that would identify you. The information is also used to ensure compliance with contracts and clinical standards. 
   
  CAREWare also allows for certain medical and support service information to be shared among providers involved with your care, in order to improve services and coordinate appropriate referrals for you. Your information is safeguarded and kept confidential. CAREWare records are maintained in an encrypted database on a secure server. In addition to designated IDOH HIV/STD/VH staff members and/or MCPHD designated staff, only providers where you receive services and who have permission to access client data can see your information. Any providers who have access to the database must sign a user confidentiality agreement and are required to keep client information secure. 
   
  The information collected about you may include, but is not limited to, demographic information, information about your HIV status, linkage and re-engagement to care, clinical information and services provided. 
   
  Any sharing of information in CAREWare follows the Health Insurance Portability and Accessibility Act ("HIPAA"), which includes but is not limited to 45 CFR 164.512(b)(1) and 45 CFR 164.506.). Sharing among your providers is for the purpose of providing, coordinating and managing your care and treatment only where you are receiving services. Counseling information and notes including psychiatric, mental health, and legal progress notes will be shared only in accordance with 45 CFR 164.508. 
  
  By this acknowledgement, I confirm that this information has been reviewed with me and understand that information about me will be entered and stored in the CAREWare database and will only be shared as outlined above.
- Telehealth Consent
  
  I provide consent to receive telehealth services from my provider. I understand and agree to the following:
  - You will be participating in a telehealth visit at a location different from where your provider is located, which may limit the ability of your provider to provide medical care. For example, your provider will not be able to conduct an in-person physical examination and cannot provide emergency medical services during a telehealth visit.
  - It is the role of your provider to determine whether or not the condition you are being diagnosed with or treated for is appropriate for a telehealth visit.
  - You or your provider may require an in-person examination before or after diagnosing or prescribing a treatment plan.
  - If you are experiencing a medical or mental health emergency, you understand you will be asked to immediately call 911 or go to the nearest emergency room.
  - This telehealth visit and future telehealth visits will be conducted with the use of real-time interactive two-way audio, video or other electronic communications. Your provider has taken steps to protect the security of information disclosed during the session, but Internet security and privacy are not guaranteed. You understand that:
    
    Security protocols could fail, potentially causing a breach of your protected health information,
    
    Information you transmit through telehealth technology may be insufficient to allow for appropriate medical decision-making by your provider (for example, poor image resolution); or
    
    Failures of equipment (for example, servers, devices) or infrastructure (for example, communications lines, power supply) may cause delays in medical evaluation and treatment, or loss of information, and you agree to hold DC harmless for any loss of protected health information that occurs due to technological failure.
  - Your provider will need to obtain an accurate medical and mental health history, condition(s) and description of current or previous medical or mental health care from you during telehealth sessions to best support diagnosis, therapy, follow-up and/or education.
  - Your provider may have other medical staff participate in your telehealth visit and you agree to medical staff participation. You have the right, at any time, to request the medical staff to leave the telehealth visit.
  - If you allow another person to participate in your telehealth visit (e.g., family, caregiver), you consent to their participation.
  - Your provider may share your identifiable information from your telehealth visits with third parties, except as prohibited by law. Your provider may separately request your consent to share identifiable information from your telehealth visits with third parties, as necessary.
  - There are potential risks to telehealth, such as technological interruptions, unauthorized access, and technical difficulties. Your provider will obtain or confirm your contact information in order to reach you in the event of a technical issue.
  - You or your provider can stop any telehealth visit if either of you feel that the videoconferencing connections are not adequate for the situation.
  - Having a telehealth visit is your choice. Even if you have agreed to the session, you can change your mind about participating in this or future telehealth sessions. You have the right to withdraw your consent.
  - This Consent lasts for as long as telehealth services continue, unless you exercise your right to withdraw your consent at any time.
  By providing your consent below, you acknowledge that you have read and understand each of the separate paragraphs above, you have had a chance to ask your provider or office staff any questions you may have, and you consent to the telehealth services and treatment provided to you by Damien Center.
- eRx Consent
  
  We use an electronic medical records system that allows electronic prescribing of medications. Prescriptions are sent to your pharmacy through a secure connection which improves the accuracy and timely transmission of your medical information. E-Prescribing greatly reduces medication errors and enhances patient safety. There are several standards that must be included in an e-prescription program. These include:
  
  • Formulary and benefit transactions- Gives the prescriber information about which
  drugs are covered by your drug benefit plan.
  
  • Medication history transaction- Provides the physician with information about
  previous and current medications the patient is taking to minimize the number of
  adverse drug reactions.
  
  • Fill status notification-Allows the prescriber to receive an electronic notice from
  the pharmacy telling them if the patient's prescription has been picked up or
  partially filled.
- Indiana Immunization Registry Consent
  
  I acknowledge that it may be necessary for my provider to report newly administered vaccines to the Children and Hoosier Immunziation Registry Program (CHIRP). More information is available on CHIRP.
- Patient Portal Consent
  
  Damien Center offers secure viewing and communication as a service to patients who wish to view parts of their records and communicate with our staff. Secure messaging can be a valuable communications tool, but has certain risks. In order to manage these risks we need to impose some conditions of participation. This form is intended to show that you have been informed of these risks and the conditions of participation, and that you accept the risks and agree to the conditions of participation.
  
  How the Secure Patient Portal Works:
  A secure web portal is a type of webpage that uses encryption to keep unauthorized persons from reading communications, information, or attachments. Secure messages and information can only be read by someone who knows the right password or pass-phrase to log in to the portal site. Because the connection channel between your computer and the website uses secure sockets layer technology you can read or view information on your computer, but it is still encrypted in transmission between the website and your computer.
  
  Protecting Your Private Health Information and Risks:
  This method of communication and viewing prevents unauthorized parties from being able to access or read messages while they are in transmission. However, keeping messages secure depends on two additional factors:
  
  1) the secure message must reach the correct email address, and
  2) only the correct individual (or someone authorized by that individual) must be able to have access to the message.
  
  Only you can make sure these two factors are present. It is imperative that our practice has your correct non-work or non-school e-mail address and that you inform us of any changes to your e-mail address. You are responsible for protecting yourself from unauthorized individuals learning your password. If you think someone has learned your password, you should promptly go to the website and change it.
  
  Types of Online Communication/Messaging:
  Online communications should never be used for emergency communications or urgent requests. If you have an emergency or an urgent request, you should contact your provider's office via telephone.
  
  Patient Acknowledgement and Agreement:
  I acknowledge that I have read and fully understand this consent form and the Policies and Procedures regarding the Patient Portal. I understand the risks associated with online communications between my physician’s office and me, and consent to the conditions outlined herein. In addition, I agree to follow the instructions set forth herein, as well as any other instructions that my physician’s office may impose to communicate with patients via online communications. I understand and agree with the information that I have been provided and am aware I may refuse to disclose my email address.
- Acknowledgement of Receipt of Notice of Privacy Practices
  
  I hereby acknowledge that I received a copy of Damien Center and Notice of Privacy Practices. I also acknowledge it was explained to me and that I have had an opportunity to ask questions to clarify my understanding of these separate documents.
  
  You may find the Notice of Privacy Practices available online CLICK HERE
- Would you like a copy of the Privacy Practices sent to your email?
- Please provide the email address where you'd like to receive the Privacy Practices.
  example@example.com

Consents and Acknowledgement
Health Information Exchange (HIE) Consent

I understand that Damien Center participates in the Carequality Framework and Commonwell Health Alliance for Health Information Exchange (HIE).
These HIEs provide a way of sharing my health information among participating doctors’ offices, hospitals, labs, radiology centers, and other providers through secure, electronic means.

I have been informed that my health information will be shared with the HIEs in order to better coordinate my care and assist providers in making more informed decisions.

I have been advised by Damien Center that I have the right to “opt-out” of the HIEs at any time. I understand that I can request to opt-out and direct Damien Center to disable access to my health information, except to the extent that disclosure of such information is permitted or mandated by law.

A) Send/Receive (my Damien Center provider will send and receive my health information with other providers that have or are currently treating me).

B) Receive Only (my Damien Center provider will NOT send, but will receive my health information from other providers that have or are currently treating me).

C) Send Only (my Damien Center provider will send, but will NOT receive my health information with other providers that have or are currently treating me).

D) Opt-Out (my Damien Center provider will NOT send and will NOT receive my health information from other providers that have or are currently treating me).
Please indicate your consent to participate in the HIE:

Attendance Policy

	Late Cancel	No-Show
Our Policy:	If you cancel your appointment with less than 24 hours' notice.	If you do not arrive for your appointment OR you arrive more than 10 minutes after your appointment started.
Consequences:	First, Second, and Third Late Cancellation: We will remind you about our policy. Fourth Late Cancellation: You will lose the privilege of scheduling appointments in advance and must use Same-Day Appointments.	First No-Show: We will remind you about our policy. Second No-Show: You will lose the privilege of scheduling appointments in advance and must use Same-Day Appointments for routine or urgent care.
How to Avoid:	Please contact us if you need to cancel or reschedule at least 24 hours in advance.	Set reminders for your appointments. If you are running late, please call us - you can avoid a No-Show and we may be able to move your appointment to another open time.
What are Same-Day Appointments?	For routine or urgent health needs, you may call us at (317) 632-0123 and be scheduled for an appointment on that day if one is available. Call early in the day, Same Day Appointments fill up quickly!
Why is this important?	Breaking our patient attendance policies: Disrupts our health center’s operating schedule. Affects other patients who could have used that appointment slot. Impacts our ability to provide timely care to you and other patients.

Signature Page
How did you hear about us?

Other
Patient/Guardian Signature
v20260303RC
Should be Empty:

New Patient Registration Form

Parent/Guardian Consent

Patient Demographics

What is your legal name?

Demographics

The Patient Portal/Healow

Household Size and Income

Health Center Sliding Fee Scale

Patient Driver's License or State Identification Card

Sexual Orientation/Gender Identity

Race/Ethnicity

Emergency Contact Information

Payment and Insurance Information

Primary Insurance

Secondary Insurance

Secondary Insurance

Preferred Hospital

Preferred Pharmacy

Consents and Acknowledgement

Consents and Acknowledgement

Attendance Policy

Signature Page