Volunteer Health Care Provider Program Eligibility Form

VOLUNTEER HEALTH CARE PROVIDER PROGRAM ELIGIBILITY FORM

CLINIC/PROGRAM/PROVIDER: GRACE MEDICAL HOME
Section 1
Does the client/patient have insurance that covers the health or dental condition?
Does anyone in the client/patient’s family have an active FL Medicaid card?
Name of the Card Holder

First NameLast Name
Medicaid Card Number
Client/Patient/Head of Household's Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number

Area CodePhone Number
Section 2
For the grid below, please only include any dependents in the household under the age of 21. Other independent adults living in the household must apply separately.

Family Size

Rows	Adults	Under 18	18-21 Student	Unborn
How many in your household?

Family Members

Rows	Name	D.O.B.	Employer	Gross Earned Income Last 4 Weeks	Gross Unearned Income Last 4 Weeks (Do not include TCA or SSI)
Self
Spouse/Partner
Child
Child
Child
Child
Child
Child

TOTAL Gross Earned Income Last 4 Weeks
TOTAL Gross Unearned Income Last 4 Weeks (Do not include TCA or SSI)
TOTAL Income
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grace Medical Home is offering a new text, email, and automated voice message program to patients (CareMessage). Examples of these messages are reminders and information about health education programs. This is a consent form. Signing this form is voluntary. Whether or not you sign, the treatment you receive from us will be the same.

Cost: There is no fee to be part of this Program. Standard text message and minute usage rates from your mobile or Internet service provider may apply.

Risks: Sending and receiving text, email and voice messages from us may impact the privacy and security of your Personal Health Information (“PHI”). Examples of PHI are: name, medical condition or insurance coverage.
- Text, email and voice messages are not encrypted. Encryption makes sure your information stays safe. Information in text, email and voice messages may not be secure.
- If you share your phone or email, or your mobile phone is lost or stolen, someone other than us may be able to access your PHI. Messages can be read, used or shared by people other than us.
I, the Patient, understand and accept each of the following:
- I authorize Grace Medical Home to send me text, email and voice messages. This includes (but is not limited to) treatment- or care-related reminders and health education information.
- Text, email, and voice messages from Grace Medical Home may contain PHI. I will be responsible for information I share with Grace Medical Home.
- This consent will be in effect as long as I receive treatment from Grace Medical Home. I can ask Grace Medical Home for a more secure form of communication, such as telephone or fax.
- I will let Grace Medical Home know if my mobile phone number changes or if I no longer want to be part of this Program, by mail, email or phone call.
- This consent is good for five (5) years. I can cancel by signing a cancellation form.
- I have a right to receive a copy of this consent form for my records.
I have read the above information and, by signing below, I confirm:
Mobile Phone Number

Area CodePhone Number
Landline Phone Number

Area CodePhone Number
Email
example@example.com
Signature of Patient or Patient's Representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Patient or Patient's Representative
Representative's Relationship to Patient
Should be Empty:

VOLUNTEER HEALTH CARE PROVIDER PROGRAM ELIGIBILITY FORM

Section 1

Section 2