Patient Intake

Thank you for choosing OIC Behavioral Health. Completion of this online form will help us to design the best plan of care. The form adheres to Privacy Practices and is in a safe and secure environment to protect private information.

"*" indicates required fields

Step 1 of 4

Is the patient 18 years of age or older?

Yes

Adult Patient Consent for Services

Patient Consent*

The providers and others here at OIC Family Medical Center want to do all we can to protect the health information we have about your health and keep it private and secure. You have a right to that information, and the right to talk to your healthcare team about your information. When we need to contact you, we will only speak to you, or people you have listed below. You should list only the numbers you wish us to use to contact you.

I consent to these terms.

Additional Contacts

I authorize OIC Family Medical Center and medical staff to discuss my healthcare information (which may include history, diagnosis, labs, test results, treatments, and other health information) with the contacts listed below. I understand that by leaving spaces blank, I am indicating my choice to be “No Information,” and I do not want any information released without my express consent. I also understand that if I want to make changes to this form, I must make the changes in writing.

Full Name

Relationship to Patient

Phone Number (555-555-5555)

Child Patient Consent for Services

Please complete the section below only if you are the parent/legal guardian of the patient. As parent/legal guardian of patient named above, I understand my child cannot receive care at OIC Family Medical Center (‘OIC’) with a non-guardian adult unless I have given written permission for this adult to bring my child. This permission also includes authorization for my child to receive immunizations during a visit with the adults listed below. Also, I give OIC permission to discuss protected health information and to release test results to the following person(s):

I authorize the following adults to bring my child for care in my absence:

Full Name

Relationship to Child

Phone Number (555-555-5555)

Patient Consent*

I also understand that I must bring my child for their first visit at OIC to ensure an accurate medical history is given. The person who brings my child must also have a full understanding of the illness my child is coming in for. This person should also know other medical conditions and/or allergies my child has. I have the right to review OIC’s Notice of Privacy Practices before signing this consent form. This form is valid for 1 year unless specified by patient in writing.

I consent to these terms.

OIC Policies

We are dedicated to serving our patients and providing quality care. Please note the following standards:

Behavior – For your safety and the safety of others, we will not tolerate rude or inappropriate behavior at any of our facilities. We value our staff and our patients and aim to treat everyone with equal respect. Displaying inappropriate behavior could result in having you or your child’s care dismissed from our practice. Thank you for your help and support in keeping our facilities safe and patient friendly.

Missed Appointments – It is important that our patients come to their scheduled appointments and arrive on time. If you are unable to come to your scheduled appointment, we ask that you contact our office 24 hours in advance so that we may adjust our schedules accordingly. If you fail to contact our office in advance, we will document the appointment missed as a ‘no show’ in the patient’s record. Excessive no shows could negatively impact you or your child’s ability to schedule appointments in the future.

Lateness – Patients arriving no more than 15 minutes late will be seen at the provider’s discretion, based on the flow of other patients in the office arriving on time. Patients arriving more than 15 minutes late for their appointment will be asked to reschedule in order to respect the time of our other patients, providers, and our clinical staff.

Patient Centered Medical Home Responsibilities

The practice is responsible for coordinating patient care across multiple settings.
The practice provides instructions for obtaining care and clinical advice during office hours and when the office is closed.
The practice functions most effectively as a medical home if patients provide a complete medical history and information about care obtained outside the practice.
The care team provides access to evidence-based care, patient/family education and self-management support.
The practice provides the scope of services available within the practice including how behavioral health needs are addressed.
The practice provides equal access to all of their patients regardless of source of payment.
The practice gives uninsured patients information about obtaining coverage.
The practice provides instructions on transferring records to the practice, including a point of contact at the practice.

If you have questions, please ask to speak with the Director of Practice Operation.

Consent*

I understand the policies listed above.

Additional Consent & Authorizations

Consent for Medical Treatment*

I/we voluntarily consent to medical treatment and diagnostic procedures provided by OIC FMC and its associated physicians, clinicians, and other personnel for myself or for the undersigned patient for whom I am the guarantor. I/we consent to the testing for infectious diseases, such as, but not limited to: Syphilis, hepatitis, and testing of drugs as deemed advisable by my physician. I/we am/are aware that the practice of medicine and surgery is not an exact science and I/we acknowledge that no guarantees have been made as to the result of treatments or examinations. If I/we choose not to consent for testing, I have the choice to opt out.