Eligibility Application English

Lake Area Free Clinic Eligibility Application - ENGLISH

Please complete the following form to determine your eligibility for medical and/or dental service at the Lake Area Free Clinic. To determine eligibility, the Lake Area Free Clinic will also request that you submit certain documents to verify your identification, address, and household income.

1General Information

2Referral Information

3Emergency Contact Information

4Payment Information

5Employment and Income Information

6Consent

7HIPPA

HIPAA (check boxes to acknowledge)
HIPAA 1*
I hereby acknowledge that I can request and review a copy of the Lake Area Free Clinic's HIPAA Notice of Privacy Practices.
HIPAA 2*
I understand that the Lake Area Free Clinic's HIPAA Notice of Privacy Practices may change periodically and that I am entitled to a copy of the Lake Area Free Clinic's revised HIPAA Notice of Privacy Practices upon request.
HIPAA 3*
I understand that, if I have questions about the Lake Area Free Clinic's HIPAA Notice of Privacy Practices, I may contact Carrey Spencer, RDH, Dental Clinic Manager at 262-569-4990.
HIPAA 4*
I understand that it is my right to refuse to sign this acknowledgement should I so choose, and that Lake Area Free Clinic will not refuse treatment to me if I refuse to sign this acknowledgement.
HIPAA 5*
I further understand that I may contact the Secretary of the U.S. Department of Health and Human Services should I have concerns regarding the Lake Area Free Clinic's privacy policies and procedures. For information on how to contact the U.S. Department of Health and Human Services, please ask Carrey Spencer, RDH Clinic Manager, noted above, for assistance.
HIPAA 6
Check this box to authorize the Lake Area Free Clinic to provide my health to information to another individual.
Name of individual I authorize the Lake Area Free Clinic to provide my health information to:
Patient Signature*

By typing my signature above, I attest that all above information is correct to the best of my knowledge. I also agree to notify the Lake Area Free Clinic of any of the changes above which could affect my eligibility.
Date:*
MM slash DD slash YYYY
Personal Representative’s Name and Relationship to Individual:
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Lake Area Free Clinic Eligibility Application - ENGLISH

General Information

Referral Information

Emergency Contact Information

Payment Information

Employment and Income Information

Consents (check boxes to acknowledge)

HIPAA (check boxes to acknowledge)

Location/Contact

Hours

Email Signup