Print and complete this form before your first visit to save time at check-in. Bring it with you, along with photo ID, your insurance card, and any current prescriptions. Need a paper copy mailed to you? Call (518) 370-1441.
What you type stays in your browser. Hometown does not receive or store anything you fill in here. Use the Print button to print a copy with your information, then bring or fax the printed form to us.
Adult Patient Registration
Hometown Health Centers
Patient information
Patient Name
Maiden Name
Address Homeless:
City
State
Zip Code
Home #
Cell #
Work #
SSN
Sex
Date of Birth
HHC can send reminders and messages by (check for yes):
Employer
Guarantor / Parent / Financially responsible party (if not the patient)
Name
Relationship to Patient
Address
City
State
Zip Code
Home #
Cell #
Work #
SSN
Sex
Date of Birth
Employer
For reporting purposes only
Marital Status:
Race:
Ethnicity:
Primary Language:
Military Status — Are you a veteran?
Household information
As a Federally Qualified Health Center, we need the following information for statistical reports.
Approximate Annual Family Income
$
Number of Family Members
Emergency contact
Name
Phone #
Address
Relationship
Insurance
Primary Insurance
ID #
Insurance Subscriber Name
Secondary Insurance
ID #
Insurance Subscriber Name
Pharmacy
Name of Pharmacy
Phone #
Address / Location
Release of information / assignment of benefits
I authorize Hometown Health Centers to release any information, including diagnosis and the records of any treatment or examination rendered to me (or my child) during the period of such care, to third-party payers and/or health practitioners.
I authorize and request my insurance company to pay, directly to Hometown Health Centers, group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
I hereby certify that to the best of my knowledge all of the above information is true and correct. I understand that program officials may verify information on this form or use information for statistical analysis. I also understand that information I supply will be kept confidential.
Payment is expected at the time of service unless other arrangements have been made. We accept cash, checks, and credit cards.
Patient / Parent / Guardian Signature
Date
Signature of HHC Staff
Date