PATIENT REGISTRATION FORM Verified By · သို႔မဟုတ္ အရက္ႏွင့္...
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Primary Language if Not English: __________________________________ Do You Need Interpreter Services? YES NO APPOINTMENT TYPE/STAFF USE ONLY Verified By: DATE REC/ENTERED: ____/____/____ STAFF INITIALS: ________________ PATIENT REGISTRATION FORM c Riverside c Safe Harbor c Pearl Street c South End c Champlain Islands c GoodHEALTH c Winooski Family RESPONSIBLE PARTY INFORMATION (Any patient under 18 must have a responsible party) PATIENT INFORMATION PLEASE COMPLETE (Fill out) entire form in Black or Blue Pen Only MEDICAL INSURANCE INFORMATION Revised March 2019 DENTAL INSURANCE INFORMATION EMERGENCY CONTACT NAME RELATIONSHIP PHONE NUMBER LAST NAME FIRST NAME MI STREET ADDRESS CITY STATE ZIP SOCIAL SECURITY # DATE OF BIRTH HOME PHONE DAY PHONE EMAIL ADDRESS LEGAL SEX MALE FEMALE CURRENT GENDER MALE FEMALE AGRICULTURAL WORKER Migrant Seasonal Are You a U.S. Veteran? Yes No Primary Care Physician FAMILY FINANCIAL INFORMATION Family/Household Size: ______________ Household Income: $ _______________ Weekly Annually Biweekly Refused Monthly As a Health Center that receives Federal funding, we are required to collect this information. All answers are confidential. MARITAL STATUS Single Separated Married Widowed Divorced Civil Union RACE African-American Native American Asian-American Pacific Islander Caucasian/White Multi-racial HOUSING STATUS Are You Homeless? YES NO If homeless, are you: Doubling Up (living with others) Shelter Street Transitional Unknown Ethnicity/Ethnic Origin: Hispanic Non-Hispanic Patient (18 years or older) Custodial Parent Guardian (proof of legal status required for treatment) LAST NAME FIRST NAME MI STREET ADDRESS CITY STATE ZIP DATE OF BIRTH HOME PHONE I currently have DENTAL insurance (see below) I currently DO NOT have DENTAL insurance I would like to apply for the SLIDING-FEE SCALE Dental Insurance Name: ____________________________________ Policy/ID Number: _________________________________________ I currently have secondary DENTAL insurance (see below) Dental Insurance Name: ____________________________________ Policy/ID Number: _________________________________________ I currently have MEDICAL insurance (see below) I currently DO NOT have MEDICAL insurance I would like to apply for the SLIDING-FEE SCALE Medical Insurance Name: ___________________________________ Policy/ID Number: _________________________________________ I currently have secondary MEDICAL insurance (see below) Medical Insurance Name: ___________________________________ Policy/ID Number: _________________________________________ PREFERRED CONTACT METHOD PHONE EMAIL TEXT MESSAGE SEXUAL ORIENTATION STRAIGHT or HETEROSEXUAL LESBIAN, GAY or HOMOSEXUAL BISEXUAL SOMETHING ELSE DON’T KNOW CHOOSE NOT TO DISCLOSE c MEDICAL c DENTAL GENDER IDENTITY MALE FEMALE TRANSGENDER MALE (Female-to-Male/FTM) TRANSGENDER FEMALE (Male-to-Female/MTF) GENDERQUEER OTHER CHOOSE NOT TO DISCLOSE PREFERRED PHARMACY PHARMACY NAME PHARMACY LOCATION CELL PHONE Burmese
Transcript of PATIENT REGISTRATION FORM Verified By · သို႔မဟုတ္ အရက္ႏွင့္...
Primary Language if Not English: __________________________________
Do You Need Interpreter Services? YES NO
APPOINTMENT TYPE/STAFF USE ONLY
Verified By:DATE REC/ENTERED: ____/____/____
STAFF INITIALS: ________________
PATIENT REGISTRATION FORM
c Riverside c Safe Harbor c Pearl Street c South End c Champlain Islands c GoodHEALTH c Winooski Family
RESPONSIBLE PARTY INFORMATION (Any patient under 18 must have a responsible party)
PATIENT INFORMATION PLEASE COMPLETE (Fill out) entire form in Black or Blue Pen Only
MEDICAL INSURANCE INFORMATION
Revised March 2019
DENTAL INSURANCE INFORMATION
EMERGENCY CONTACTNAME RELATIONSHIP PHONE NUMBER
LAST NAME FIRST NAME MI
STREET ADDRESS CITY STATE ZIP
SOCIAL SECURITY # DATE OF BIRTH HOME PHONE DAY PHONE
EMAIL ADDRESS
LEGAL SEX
MALE
FEMALE
CURRENT GENDER MALE
FEMALE
AGRICULTURAL WORKER
Migrant Seasonal
Are You a U.S. Veteran?
Yes No
Primary Care Physician FAMILY FINANCIAL INFORMATION
Family/Household Size: ______________
Household Income: $ _______________
Weekly Annually
Biweekly Refused
Monthly
As a Health Center that receives Federal funding, we are required to collect thisinformation. All answers are confidential.
MARITAL STATUS
Single Separated Married Widowed Divorced Civil Union
RACE
African-American Native American Asian-American Pacific Islander Caucasian/White Multi-racial
HOUSING STATUS Are You Homeless? YES NO
If homeless, are you: Doubling Up (living with others) Shelter Street Transitional Unknown
Ethnicity/Ethnic Origin: Hispanic Non-Hispanic
Patient (18 years or older) Custodial Parent Guardian (proof of legal status required for treatment)
LAST NAME FIRST NAME MI
STREET ADDRESS CITY STATE ZIP
DATE OF BIRTH HOME PHONE
I currently have DENTAL insurance (see below)
I currently DO NOT have DENTAL insurance
I would like to apply for the SLIDING-FEE SCALE
Dental Insurance Name: ____________________________________
Policy/ID Number: _________________________________________
I currently have secondary DENTAL insurance (see below)
Dental Insurance Name: ____________________________________
Policy/ID Number: _________________________________________
I currently have MEDICAL insurance (see below)
I currently DO NOT have MEDICAL insurance
I would like to apply for the SLIDING-FEE SCALE
Medical Insurance Name: ___________________________________
Policy/ID Number: _________________________________________
I currently have secondary MEDICAL insurance (see below)
Medical Insurance Name: ___________________________________
Policy/ID Number: _________________________________________
PREFERRED CONTACT METHOD
PHONE EMAIL TEXT MESSAGE
SEXUAL ORIENTATION
STRAIGHT or HETEROSEXUAL
LESBIAN, GAY or
HOMOSEXUAL
BISEXUAL
SOMETHING ELSE
DON’T KNOW
CHOOSE NOT TO DISCLOSE
c MEDICAL c DENTAL
GENDER IDENTITY
MALE
FEMALE
TRANSGENDER MALE (Female-to-Male/FTM)
TRANSGENDER FEMALE (Male-to-Female/MTF)
GENDERQUEER
OTHER
CHOOSE NOT TO DISCLOSE
PREFERRED PHARMACYPHARMACY NAME PHARMACY LOCATION
CELL PHONE
Burmese
ျပနလညျပငဆင မတ 2019
လနာစာရငးသြငးျခငးေဖာင အတညျပသ-
မတတမးတင/ ထညသြငး ေန႔စြ- __ / __ /___
ဝနထမးအမည- ________________________ ခနးဆမႈ အမးအစားမား/ ဝနထမးမ ျဖညစြကရနသာ ေဆးကသမႈ သြားကနးမာေရး
Riverside Safe Harbor Pearl Street South End Champlain Islands GoodHEALTH Winooski Family
လနာသတငးအခကအလက ေကးဇးျပ၍ ျပညစေအာင (ျဖညစြကပါ) ေဖာငတစခလးက ေဘာပငအနက သ႔မဟတ အျပာသာ အသးျပပါ။ ေနာကဆးစာလး ပထမစာလး အလယ
အမလပစာ ၿမ႕ ျပညနယ ေဒသကဒ
လမႈဖလေရး # ေမြးေန႔ အမဖနး ေန႔ဘကဖနး ဆလဖနး
အးေမးလ ႏစသကေသာ ဆကသြယပ
ဖနး အးေမးလ ဖနးစာတ
အမေထာင လမး အဂၤလပမဟတပါက အဓကေျပာေသာ ဘာသာစကား- _______________________________
လလြတ သးသန႔ခြေန အာဖရကန-အေမရကန မရငး အေမရကန ဘာသာျပနဝနေဆာငမႈလအပပါသလား။ ဟတ မဟတ
အမေထာငရ တစခလပ အာရ-အေမရကန ပစဖတကၽြနးသား
ကြာရငး လငတလကထပ ကာေကးရနး/လျဖ လမးစ လမးစ/ ဇာတ မးႏြယ- ဟစ(စ)ပနးနစ ဟစ(စ)ပနးနစ မဟတသ
အထးၾကပမတေစာငေရာကမႈဆငရာ သမားေတာ စကပးေရးလပသား သငသည U.S. စစမႈထမးေဟာငး မသားစေငြေၾကးအခကအလက
ေရႊ႕ေျပာငး ရာသလက ဟတ မဟတ မသားစ/အမေထာငစ အရြယအစား- ___________
တရားဝငလငအမးအစား
အမးသား
အမးသမး
လကရ လငအမးအစား
အမးသား
အမးသမး
လငသတမတခက လငတမးၫႊတမႈ
လငကြႏစသကသ သ႔မဟတ ဆန႔ကငဘကလငႏစသကသ
အမးသမးခငးႏစသကသ, အမးသားခငးႏစသကသ (သ႔) လငတႏစသကသ
လင၂ မးစလးႏစသကသ
အျခားအမးအစား
မသပါ
မေျဖဆလပါ
အမးသား
အမးသမး
လငေျပာငးလထားေသာ အမးသား (အမးသမးမ အမးသားသ႔/FTM)
လငေျပာငးလထားေသာ အမးသမး (အမးသားမ အမးသမးသ႔/MTF)
အမးသမးကသ႔ဝတစားေနထငေသာ အမးသား
အျခား
မေျဖဆလပါ
အမေထာငစဝငေငြ- $ _____________________
အပတစဥ ႏစစဥ ၂ ပတတစႀကမ ျငငးဆန လစဥ
ျပညေထာငစေထာကပေငြကလကခရရေသာ ကနးမာေရးစငတာတစခအေနႏင ထသတငး အခကအလကကစေဆာငးရနလအပပါသည။ အေျဖမားအားလးက လ႕ဝကထားအပပါသည။ အမရာအေျခအေန သငသည အးအမမျဖစပါသလား။ ဟတပါသည မဟတပါ
အကယ၍အးအမမျဖစပါက ၂ ဆတး (အျခားသမားႏင ေနထငပါသလား) နားခရာေနရာ လမး အကးအေျပာငး မသပါ
ႏစသကရာေဆးဆင
ေဆးဆငအမည ေဆးဆငတညေနရာ
အေရးေပၚဆကသြယရန အမည ေတာစပပ ဖနးနပါတ
တာဝနရအပထနးသ အခကအလက (အသက 18 ႏစေအာက လနာတငးတြင တာဝနရေသာ အပထနးသ ရရပါမည)
လနာ (အသက ၁၈ ႏစႏင အထက) အပထနးသ မဘ အပထနးသ (ေဆးကသမႈအတြက တရားဝငေတာစပပသကေသလအပပါသည။)
ေနာကဆးစာလး ပထမစာလး အလယ
အမလပစာ ၿမ႕ ျပညနယ ေဒသကဒ
ေမြးေန႔ အမဖနး
သြားကနးမာေရးအာမခသတငးအခကအလက ကနးမာေရးအာမခသတငးအခကအလက လကရ ကြႏပတြင သြားအာမခရပါသည (ေအာကတြင ဖတပါ) လကရ ကြႏပတြင သြားအာမခမရပါ ကၽြႏပသည ေလာေဈးအစအစဥက ေလာကထားလပါသည
ကြႏပတြင လကရကနးမာေရးအာမခရပါသည။ (ေအာကတြင ဖတပါ) ကြႏပသည လကရတြင ကနးမာေရးအာမခမရပါ။ ကၽြႏပသည ေလာေဈးအစအစဥက ေလာကထားလပါသည
သြားကနးမာေရးအာမခ အမည: ________________________________________ ကနးမာေရးအာမခအမည- _____________________________________________ မဝါဒ/ID နပါတ- ___________________________________________________ မဝါဒ/ID နပါတ- ____________________________________________________
ကြႏပတြင လကတေလာ ဒတယဥးစားေပး သြားကနးမာေရးအာမခရပါသည။ (ေအာကတြငဖတပါ။)
ကြႏပတြင လကတေလာတြင ဒတယဥးစားေပး ကနးမာေရးအာမခရပါသည။ (ေအာကတြငဖတပါ။)
သြားကနးမာေရးအာမခ အမည- ________________________________________ ကနးမာေရးအာမခအမည- _____________________________________________
မဝါဒ/ID နပါတ- ___________________________________________________ မဝါဒ/ID နပါတ- ____________________________________________________
READ ONLY
Burmese
Consent for Treatment and Consent to Release
Health Information for Treatment, Payment and Health Care Operations
I. Consent for treatment:
I hereby give my consent for treatment for myself, or the named patient (of whom I am the parent or legal
guardian who has the right to consent to treatment for the named patient) to the Community Health Centers of
Burlington, Inc. (CHCB). Treatment may include health screening, diagnosis, medical treatment, dental care,
social services, mental health or drug and alcohol screening, assessment, diagnosis and treatment, and
psychiatry services.
II. Consent to release of health information, including health/treatment records for treatment, payment and
health care operations:
I consent to the use within CHCB and the disclosure to persons or organizations outside of CHCB of my (or of
the named patient for whom I am the parent or legal guardian) medical, dental, drug and alcohol, mental
health, psychiatry and other treatment and health records ("health information") by CHCB for the following
purposes:
A. Use of health information by or for CHCB for treatment, payment, and health care operations:
Providing treatment by CHCB staff;
Conducting health care operations of CHCB including financial or quality
assurance audits and/ or training.
Payment for services provided by CHCB. CHCB is authorized to obtain payment for health care
services and can provide health information to insurance companies, workers compensation insurers
or other agencies that pay for health services, as identified in my CHCB registration form or other
updated insurance information on file with CHCB.
B. Disclosure of health information to persons or organizations outside of CHCB for treatment
purposes:
CHCB is authorized to provide all necessary health information as determined by CHCB, including
information about treatment for substance use disorders to any of the following health providers if I am
referred there for medical treatment:
Hospitals: University of Vermont Medical Center (UVMMC), Copley Hospital, Porter Hospital,
Northwestern Medical Center, Central Vermont Medical Center (CVCA), Dartmouth Hitchcock
Medical Center (DHMC)
Allergy: Timberlane Allergy & Asthma Associates
Audiology: Adirondack Audiology Associates
Cardiology: CVCA, Central VT Cardiology, NWMC Cardio, DHMC Cardiology
Dermatology: Dorset St. Dermatology, Four Seasons Dermatology
Gastroenterology: VT Gastroenterology, Northwestern Medical Center
Home Health: Bayada Home Health, UVMMC Home Health & Hospice
Neurology: DHMC Neurology, Neurological Associates of Burlington
OB/GYN: Lake Champlain Gynecology, Maitri, VT Gynecology
Ortho: NWMC Ortho, Mansfield Ortho
Oximetry: Lincare
Pain Clinic: VT Interventional Spine Center, VT Pain Management, UVMMC Pain Management
Radiology: CVMC Radiology, NWMC, Porter, Copley and VT Open MRI
Sleep Study: VT Medical Sleep Disorder, UVMMC Sleep Program
Urology: DHMC Urology, Green Mountain Urology
Veterans Veterans Administration Programs and Facilities
Physical Therapy:(PT) PT 360, All Wellness PT, Appletree Bay, Catamount PT,
Champlain PT, Choice PT, Cornerstone PT, DEE PT, Edge PT, Elite Health & Burmese
ကသမႈ၊ ေငြေပးေခမႈႏင ကနးမာေရး ေစာငေရာကမႈမားအတြက ကသမႈ သေဘာတညခကႏင ကနးမာေရးအခကအလက ထတျပနရန သေဘာတညခက
I. ကသမႈအတြက သေဘာတညခက- ကၽြႏပကယတင သ႔မဟတ အမညေဖာျပထားေသာ လနာအတြက (ကၽြႏပသည ထသ၏ မဘ သ႔မဟတ တရားဝငအပထနးသျဖစကာ
အမညပါလနာအတြက သေဘာတညခြင ရပါသည) သေဘာတညခကအား Community Health Centers of Burlington, Inc. (CHCB) က
ေပးအပပါသည။ ကသမႈမားတြင ကနးမာေရးစစေဆးျခငး၊ ေရာဂါရာေဖြျခငး၊ ေဆးကသျခငး၊ သြားကနးမာေရး၊ လမႈဝနေဆာငမႈမား ၊ စတကနးမာေရး
သ႔မဟတ အရကႏင မးယစေဆး စစေဆးျခငး၊ အကျဖတျခငး၊ ေရာဂါရာေဖြကသျခငးႏင စတေရာဂါ ဝနေဆာငမႈမား ပါဝငပါသည။
II. ကသမႈအတြက ကနးမာေရး/ကသမႈ မတတမးမား၊ ေငြေပးေခမႈႏင ကနးမာေရးေစာငေရာကမႈမား အပါအဝင
ကနးမာေရးအခကအလကမား- ကၽြႏပ၏ (သ႔မဟတ ကၽြႏပမ မဘ၊ တရားဝငအပထနးသျဖစေသာ အမညပါကေလး၏) ေဆးကမႈ၊ သြားကနးမာေရး၊ မးယစေဆးႏင အရက၊ စတကနးမာေရး၊
စတေရာဂါႏင အျခား ကနးမာေရး မတတမးမား ("ကနးမာေရး အခကအလကမား") က CHCB အတြငးသာ သးရနႏင CHCB ျပငပရ လ သ႔မဟတ
အဖြ႔အစညးမားက ၾကညရႈခြငျပျခငးအား CHCB မ ေအာကပါ ရညရြယခကမားအတြက ခြငျပရန သေဘာတပါသည-
A. ကနးမာေရးအခကအလကမားအား ကသမႈ၊ ေငြေပးေခမႈ ႏင ကနးမာေရးေစာငေရာကမႈတ႔အတြက CHCB မ အသးျပရန- CHCB ဝနထမးမ ကသမႈေပးျခငး-
ေငြေၾကးႏင အရညအေသြးအကျဖတမႈ ႏင/သ႔မဟတ သငတနးေပးျခငး အပါအဝင CHCB ၏ ကနးမာေရး ေစာငေရာကမႈမား ျပလပျခငး
CHCB ဝနေဆာငမႈမားအတြက ေငြေပးျခငး။ CHCB သည ကၽြႏပ၏ CHCB စာရငးသြငးပစ သ႔မဟတ အျခားေသာ CHCB အာမခ အခကအလက ပစမားတြင ေဖာျပထားသကသ႔ ကနးမာေရး ဝနေဆာငမႈမားအတြက ေငြေပးေခမႈက ရယႏငၿပး အာမခလပငနးမား၊ အလပသမားနစနာေၾကး အာမခမားႏင ကနးမာေရးဝနေဆာငမႈေပးေသာ အျခားအဖြ႔မားသ႔ ကနးမာေရးအခကအလကမားက မေဝႏငပါသည။
B. ကသရနအတြက CHCB ျပငပရ လ သ႔မဟတ အဖြ႔မားက ကနးမာေရးအခကအလကမား ၾကညရႈခြငေပးျခငး- CHCB သည ကၽြႏပအား ေအာကပါ ကနးမာေရးဝနေဆာငမႈေပးသမားသ႔ ကၽြႏပက လႊေပးရပါက မးယစေဆးသးျခငး ကသမႈ
အခကအလကမားအပါအဝင CHCB က လအပသညဟ သတမတေသာ ကနးမာေရးအခကအလကမားက လႊေျပာငးေပးရန ခြငျပပါသည-
ေဆးရမား- University of Vermont Medical Center (UVMMC), Copley Hospital, Porter Hospital, Northwestern Medical Center, Central Vermont Medical Center (CVCA), Dartmouth Hitchcock Medical Center (DHMC)
ဓာတမတညမႈ- Timberlane Allergy & Asthma Associates
အၾကားအာရဆငရာ- Adirondack Audiology Associates
ႏလး- CVCA, Central VT Cardiology, NWMC Cardio, DHMC Cardiology
အေရျပား- Dorset St. Dermatology, Four Seasons Dermatology
အစာအမအလမးေၾကာငး- VT Gastroenterology, Northwestern Medical Center
ေနအမကနးမာေရး- Bayada Home Health, UVMMC Home Health & Hospice
အာရေၾကာ- DHMC Neurology, Neurological Associates of Burlington
OB/GYN: Lake Champlain Gynecology, Maitri, VT Gynecology
အရး- NWMC Ortho, Mansfield Ortho
Oximetry: Lincare
နာကငမႈ- VT Interventional Spine Center, VT Pain Management, UVMMC Pain Management
ေရဒယဓာတမန- CVMC Radiology, NWMC, Porter, Copley and VT Open MRI
အပစကမႈဆငရာ- VT Medical Sleep Disorder, UVMMC Sleep Program
ဆးလမးေၾကာငး- DHMC Urology, Green Mountain Urology
စစမႈထမးေဟာငးမား စစမႈထမးေဟာငး စမေရးအစအစဥမားႏင ခစားခြငမား
ရပပငးကသမႈ- (PT) PT 360, All Wellness PT, Appletree Bay, Catamount PT, Champlain PT, Choice PT, Cornerstone PT, DEE
PT, Edge PT, Elite Health & Wellness, Essex PT, Every Woman, Evolution Therapy & Yoga, Excel PT, Fairfax PT, Forever Fit,
Genesis PT, Green Mtn. PT, Injury & Health Management Solutions, Inspire PT, Island PT, Living Well Center for Integrated
Health, Long Trail PT, On Track PT, Peak PT, Pelvic Health, Phoenix PT, Pinnacle PT, Rehab Gym, Transitions PT,
Timberlane PT, Vasta PT, and Vermont PT.
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Wellness, Essex PT, Every Woman, Evolution Therapy & Yoga, Excel PT, Fairfax
PT, Forever Fit, Genesis PT, Green Mtn. PT, Injury & Health Management Solutions,
Inspire PT, Island PT, Living Well Center for Integrated Health, Long Trail PT, On
Track PT, Peak PT, Pelvic Health, Phoenix PT, Pinnacle PT, Rehab Gym, Transitions
PT, Timberlane PT, Vasta PT, and Vermont PT.
CHCB is authorized to provide all health information to other health providers or agencies not
listed who may be involved in my care (except for information concerning treatment for drug or
alcohol abuse for which a separate consent is required);
III. Termination and restrictions of this consent: I understand that I have the right to revoke this consent at any time, but revoking this consent will not
affect any actions which were taken by CHCB in reliance on this consent before I revoked it. If not
previously revoked, this consent will terminate on the following date, event, or condition: _
if none is indicated, this consent will terminate three years after the last date of services to me.
I understand that I may request restrictions on the use or disclosure of my health information for the
purposes described in this consent and that CHCB may or may not agree to requested the restrictions. I also
understand that except for those restrictions on use or disclosure of health information to which it agrees,
CHCB will not be able to provide services to me (or the named patient) without this signed consent.
IV. Assignment of Benefits
I hereby assign to CHCB any and all payments to which I am entitled under Medicaid, Medicare, or any health
insurance policy for health care, behavioral health, psychiatry or dental health services rendered to me by CHCB.
I further authorize CHCB to bill and receive payment directly from Medicaid /Medicare or my insurance carrier(s)
for those services that CHCB delivered and for which I may be entitled to insurance coverage. I also authorize
CHCB
to give Medicaid / Medicare or my health insurance carrier(s) any information necessary for billing
purposes for services provided for such periods of time as I have received or am receiving health screening,
diagnosis, medical treatment, dental care, social services, mental health or drug and alcohol screening,
assessment, diagnosis and treatment, and psychiatry services.
I understand and acknowledge that I am financially responsible for any unpaid balances incurred as a result
of my care at CHCB.
I understand that, to the best of my knowledge, the demographic information I have provided is true and
correct.
I hereby acknowledge that I have been offered a copy of CHCB's Payment Expectations document and
understand and agree to adhere to these expectations.
I hereby acknowledge that I have been offered a copy of the Notice of Privacy Practices and understand CHCB
will use my protected health information in accordance with privacy law.
I understand that the Community Health Centers of Burlington, Inc. may use any e-mail address or mobile
phone number provided to contact me for appointment reminders or other announcements. I understand that
e-mail addresses and mobile phone numbers will not be sold to a third party or used for marketing purposes.
I have read this Consent for Treatment & Consent to Release of Health Information, and I understand and
knowingly consent to its content.
Name of Patient: Date of Birth _
Patient Signature: Date: _
Parent/Guardian: _
Parent/Guardian Signature: Date: _
Revised March 2019Burmese
ျပနလညျပငဆင မတ 2019
စာရငးတြငမပါေသာလညး ကၽြႏပ၏ ကနးမာေရး ေစာငေရာကမႈအတြက အျခားေသာ ကနးမာေရး ေစာငေရာကသမားသ႔ ကနးမာေရး
အခကအလကအားလး (သးသန႔ သေဘာတညခကလေသာ အရကႏင မးယစေဆးသးမႈ အခကအလကမားမအပ) က မေဝခြငအား CHCB
က ေပးအပပါသည-
III. ယခသေဘာတညခက အဆးသတျခငးႏင ကန႔သတခကမား- ယခသေဘာတညခကက အခနမေရြး ရပသမးႏငေၾကာငးႏင ယခသေဘာတညခက ရပသမးျခငးသည, CHCB လပေဆာငခကမားက မညသညသကေရာကမႈမမရေၾကာငး သေဘာတညခကႏငပတသကၿပး မရပသမးမကပင နားလညပါသည။ ယခငက မရပသမးထားပါက ယခ သေဘာတညခကသည ေအာကပါ ေန႔စြ၊ အေျခအေန သ႔မဟတ အျဖစအပကတြင အဆးသတပါမည- ____________ တစခမ မေဖာျပထားပါက ယခသေဘာတညခကသည ကၽြႏပ ေနာကဆးဝနေဆာငမႈ ရယထားသညမ သးႏစအၾကာတြင သကတမးကနပါမည။
ယခသေဘာတညခကပါ ကၽြႏပ၏ ကနးမာေရးအခကအလကမား အသးျပျခငး သ႔မဟတ ၾကညရႈျခငးအတြက ကန႔သတခကမားက ကၽြႏပမ ေတာငးဆႏငၿပး ထေတာငးဆခကမားက CHCB မ သေဘာတျခငး သ႔မဟတ သေဘာမတျခငး ရႏငသညက ကၽြႏပမ နားလညပါသည။ သေဘာတထားေသာ ကနးမာေရးအခကအလကမားက သးျခငး သ႔မဟတ ၾကညရႈျခငးအတြက အဆပါ ကန႔သတခကမားမအပ ယခ လကမတထးထားေသာ သေဘာတညခကမပါဘ CHCB သည ကၽြႏပ (သ႔မဟတ အမညပါလနာအား) ဝနေဆာငမႈ မေပးႏငသညက ကၽြႏပနားလညပါသည။
IV. အကးခစားခြငဆငရာ လႊအပခက ကၽြႏပက CHCB အား Medicaid, Medicare သ႔မဟတ ကနးမာေရး၊ အျပအမကနးမာေရး၊ စတေရာဂါ သ႔မဟတ သြားကနးမာေရးတ႔အတြက မညသည ကနးမာေရးအာမခမဆ ကၽြႏပအကးဝငသမအတြကCHCB အား ေပးေခမႈ အားလးအတြက လႊအပပါသည။ ထ႔အျပင ကၽြႏပသည အာမခ အက းခစားခြင ရရႏငသညအခါ ဝနေဆာငမႈ အဖြ႔အစညးက ေပးခေသာ ယငးဝနေဆာငမႈမားအတြက ကၽြႏပ၏ အာမခကမၸဏ(မား) သ႔မဟတ Medicaid ထသ႔ ကသငေငြေတာငးခလႊာ ေပးပ႔ရနႏင ယငးတ႔မ ေပးေခမႈက လကခရန ဝနေဆာငမႈ အဖြ႔အစညးတငးအား တာဝနလႊအပပါသည။ ထ႔အျပင Medicaid / Medicare သ႔မဟတ မညသည ကနးမာေရးအမခ(မား) သ႔မဆ ကနးမာေရး ေဆးစစမႈ၊ ေရာဂါစစေဆးမႈ၊ ေဆးကသမႈ၊ သြားကနးမာေရး၊ လမႈဝနေဆာငမႈမား၊ စတကနးမာေရး သ႔မဟတ အရကႏငမးယစေဆး စစေဆးမႈ၊ အကျဖတမႈ၊ ေရာဂါရာေဖြမႈႏင စတေရာဂါ ဝနေဆာငမႈမားက ကၽြႏပ ရယဆ သ႔မဟတ ရသခေသာ အခနကာလအတြက ေငြေပးေခရန လအပေသာ မညသညအခကအလကကမဆ မေဝခြငအား CHCB က ေပးအပပါသည။
CHCB တြင ကသမႈအတြက မညသည ေငြေပးရနကနမႈမဆအတြက ကၽြႏပတြင တာဝနရေၾကာငး နားလညပါသည။
မနကနေသာ လဥးေရစာရငးအခကအလကမားကသာျဖညစြကရမညျဖစေၾကာငး နားလညပါသည။
CHCB ၏ ေငြေပးေခမႈ ခန႔မနးတြကဆခက စာရြကစာတမး မတက ကၽြႏပအား ေပးအပၿပးျဖစကာ အဆပါ ခန႔မနးတြကဆခကမားက နားလညကာ လကနာမညအေၾကာငး သေဘာတပါသည။
ကြႏပအား ကယေရးကယတာကငထး အသေပးစာ မတတစေစာငေပးထားၿပး CHCB အေနႏင ကြႏပ၏ ကာကြယထားရအပေသာ ကနးမာေရးသတငးအခကအလကမားက ဥပေဒႏငအညအသးျပမညအေၾကာငး နားလညပါသည။
Burlington, Inc. လထကနးမာေရးစငတာသည ခနးဆခကကသတေပးရနႏင အျခားေသာအသေပးေၾကျငာခကမား ျပလပရန မညသညအးေမးလႏင မဘငးဖနးနပါတမဆအသးျပၿပး ကြႏပက ဆကသြယမညအေၾကာငးနာလညပါသည။ အးေမးလလပစာမားႏင မဘငးဖနးနပါတမားက တဆငျပနလညေရာငးချခငးမျပရနႏင ေစးကြကရာျခငးရညရြယခကမားအတြကအသးမျပရန နားလညပါသည။
ေဆးကသမႈသေဘာတညခကႏင ကနးမာေရးအခကအလကမားအသးျပရနသေဘာတညခကကဖတရၿပးေနာက နားလညသေဘာတပါသည။
ျဖည
စြကရန
လနာအမည- __________________________________________________________ ေမြးေန႔ ________________________________
လနာလကမတ- ________________________________________________________ ေန႔စြ- _________________________________
မဘ/အပထနးသ- _______________________________________________________________________________________________
လနာလကမတ- ________________________________________________________ ေန႔စြ- _________________________________
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