Do you require safety caps on medication bottles?
Yes ______________
No_____________
Signature ______________________________Date______
PLEASE READ THE FOLLOWING CAREFULLY:
The Community Clinic will do everything possible to keep the medications
prescribed on the $4.00 generic medication list.
Are you able to pay for your own medications?
Yes_______
No______
Signature_____________________________Date_______
Community Clinic of Joplin
701 S. Joplin Avenue Joplin, Missouri 64801 (417) 624-5500
Dear Community Clinic Client:
It is very important for you to follow through with all lab work, x-rays,
medical referrals, and clinic appointments. When referred outside of the
clinic, there may occasionally be an appointment when payment
arrangements will have to be made. If the appointment is at one of the
local hospitals, you need to sign up for the hospitals “charity care”
program. This may cover all or part of the costs. Failure to follow the
doctor’s orders or prescribed treatment plan, for example: referral to
smoking cessation class, diabetic education class, weight loss class, will
result in being denied further services.
If you are referred to a physician outside the clinic, we will schedule the
appointment for you. If you have a home phone, we will contact you with
the referral information. If you do not have a phone number where you
can be reached, it is your responsibility to contact us for the
appointment information at 417-624-5500, ext. 13 or 15 (medical) or ext,
27 (dental).
FAILURE TO KEEP SCHEDULED APPOINTMENTS WILL
RESULT IN YOU BEING DENIED FURTHER SERVICES AT THE
COMMUNITY CLINIC.
If I need to cancel an appointment, I will notify the clinic within 24
hours before my scheduled appointment time.
I will follow through with all recommended lab work, x-rays, medical
referrals, and scheduled clinic appointments. I understand that if I fail to
follow through with scheduled medical services and appointments, I will
forfeit my right to be seen at the Community Clinic.
___________________________________
Signature
Community Clinic of Joplin
__________________
Date
FEDERAL PRIVACY ACT LAW
Acknowledgement of Receipt of Notice of Privacy Practice
I have received a copy of the Privacy Practices for the Joplin Community Clinic.
(Any information we receive is for office use only)
Name of Patient
(please print) _____________________________________________________
Patient Signature __________________________________________________
Date___________________________________
Signature of Patient Representative (Required if the patient is a minor or an adult
who is unable to sign this form:
________________________________________________________________
Relationship of Patient Representative to Patient:
________________________________________________________________
Community Clinic of Joplin