Combined Patient Application

Lackey Clinic Patient Application
Use the flag in the top right corner to change the language of the form.

Utiliza la bandera en la esquina superior derecha para cambiar el idioma del formulario.
I am applying to...*

become a new patientrecertify my patient status
If you know your Lackey Patient Number (Lackey MRN), please enter it below.
When was the last time you received medical care at Lackey Clinic?*

Less than a year agoMore than a year ago

Lackey Clinic Patient Application

Demographic and Contact Information
Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Only Applicants 18 years or older are eligible.
Social Security Number or ITIN
Gender*
What is your citizenship status?*
Phone Number*
Please enter a valid phone number.
Type of phone*
Email Address
What is the best way for us to communicate with you?*
By providing my e-mail address and phone number to Lackey Clinic, I permit the use of my e-mail and phone number to receive email and text communications.
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact (First and Last Name)*
I give my authorization to disclose my Protected Health Information to the person listed in the box.
Emergency Contact Phone Number*
Please enter a valid phone number.
Relation to Emergency Contact*
How did you hear about us? *
Demographics
Marital Status*
Housing*
Race*
Language*
Other Language:*
Highest Degree of Education*
Employment*
Are you legally disabled and receiving disability?*

YesNo
Please add information for your spouse.*
Does your spouse receive any income (wages, self employed, disability, social security, etc.)?

YesNo
Do you claim dependent(s) on your taxes?*

YesNo
Please add information for all dependents.*
Does someone claim you as a dependent on their taxes?*

YesNo
Please add information for the person who claims you as a dependent.*

Lackey Clinic Patient Application

Patient Medical Information
What is your main medical and/or dental concern? *
Do you think your concern is urgent?*

YesNoUnsure
Why is your concern urgent? *
If you are having a life-threatening medical emergency please call 911 and seek care immediately.

Lackey Clinic Patient Application

Patient Medical Information
Please provide information for when you received care and where in the past two years. Include any previous primary care providers, specialists, Emergency Departments, Urgent Cares, psychologists, psychiatrists, counselors, or other healthcare providers you've seen in the past two years.*
If you have not received medical care, write-in "None".
Are you currently pregnant or think you might be?*

YesNoUnsure
Lackey Clinic is unable to provide prenatal care. We are only able to provide primary care to pregnant women who are ineligible for Medicaid and receiving prenatal care from outside the clinic.
Do you currently take any prescription medications for chronic pain (pain that has lasted for more than 6 months) or mental health conditions?*

YesNo
Please list which prescription medications you take for chronic pain/mental health conditions.*
Have you ever been diagnosed with a serious mental health condition (such as schizophrenia, schizoaffective disorder, bipolar I disorder, etc.) or have you ever required psychiatric hospitalization?*

YesNo
Please provide details about the serious mental health condition(s) and/or psychiatric hospitalization(s).*

1620 Old Williamsburg Road, Yorktown, VA 23690
Phone: (757) 886-0608 Fax: (757) 369-3821

AUTHORIZATION FOR USE OF PROTECTED HEALTH INFORMATION
Use of Medical Records

1. INDIVIDUAL PATIENT (OR PERSONAL REPRESENTATIVE) CONFIRMING THE AUTHORIZATION

Patient's Name: {name}

Date of Birth: {dateOf}

Social Security Number: {socialSecurity8}

2. NOTICE OF PRIVACY PRACTICES

I am aware of Lackey Clinic’s Notice of Privacy Practices (click link to view). I understand that I may request a copy in person at Lackey Clinic or print from this site.

3. THE USE AUTHORIZED

I voluntarily give my authorization to Lackey Clinic to access my protected health information as needed for my medical diagnosis and treatment. This includes access to my complete medical chart in Epic iCare electronic health records.

I understand Lackey Clinic may get any data regarding my medication history. This includes data that may be held by the Virginia Prescription Monitoring Program and other sources.
Electronic Signature*

I understand that by typing my name in the below textbox and clicking "Next", I am electronically signing this document.
Please type your first and last name into the textbox below as your electronic signature.*
Date*

MonthDayYear

Patient Attestation and Agreement

By electronically signing below:
- I pledge all information provided to Lackey Clinic for the purpose of my patient application or recertification is true to the best of my knowledge. I understand this information may need to be verified and that withholding information or giving false information will make me ineligible for care.
- I understand if my income changes or if I become insured, including through Medicaid or Medicare, I must notify the clinic of these changes immediately. I understand any falsification or witholding of information regarding income or insurance status will result in suspension or dismissal from the clinic.
- I understand if I become or continue to be a Lackey Clinic Patient, I am responsible for renewing my Lackey Clinic Patient status. I understand I will not be able to receive care or medications if my Lackey Clinic Patient status is expired.
- I understand if I become or continue to be a Lackey Clinic Patient, I am required to bring in my 1040 (tax statements) immediately after filing and will not wait until my next recertification.
- I consent to necessary treatment, laboratory test(s), and consultations recommended by my medical and/or dental team as needed for my health if I become or continue to be a Lackey Clinic Patient.
- I authorize my medical and financial information to be shared with other health care providers, pharmaceutical companies, and RXPartnership, including their designees, as needed for audit or medical/dental treatment purposes if I become or continue to be a Lackey Clinic Patient.
- I understand if I become or continue to be a Lackey Clinic Medical Patient, additional documentation may be requested as needed when ordering medication.
- I authorize LMAP (Lackey Medication Assistance Program) caseworkers to become my advocate in ordering medications if I become or continue to be a Lackey Clinic Medical Patient. In doing so, I authorize them to sign the application forms and reorder medications as needed on my behalf.
- I understand if I become or continue to be a Lackey Clinic Dental Only Patient, I will only be eligible to be seen by the Lackey Clinic Dental Department. I understand that I am not eligible for medical services or medications provided by Lackey Clinic.
- Disclaimer for Medicaid eligible patients: Please be advised, because of the restrictions given to us by other health care providers and pharmaceutical companies, patients who are currently uninsured but may be eligible for Medicaid may receive limited services. These services include but are not limited to: specialty care, surgeries, and certain medications.
- Disclaimer for undocumented patients: Please be advised, because of restrictions given to us by other health care providers and pharmaceutical companies, undocumented patients may receive limited services. These services include but are not limited to: specialty care, surgeries, and certain medications. [Le informamos que como consecuencia a las restricciones impuestas a los servicios provistos a pacientes indocumentados, por proveedores y compañías farmacéuticas, usted podrá recibir únicamente servicios limitados en la Clínica de Lackey. Estos servicios limitados incluyen pero no se limitan a, cuidados especiales, cirugía y solo ciertos medicamentos.]
Electronic Signature*

I understand that by typing my name in the below textbox and clicking "Next", I am electronically signing this document.
Please type your first and last name into the textbox below as your electronic signature.*
attest_signature
Date*

MonthDayYear

Lackey Clinic Patient Application

Document Upload
In order to determine your eligibility, we need a driver's license (or other photo ID) and proof of income for everyone in your household. Please use the document upload or Take Photo button to attach your documents. Please make sure all documents/pictures are clear and not blurry. You may also submit your application now and email your documents to enroll@lackeyhealthcare.org, fax them to 757-369-3821 (Attn: Eligibility), or drop them off during business hours.

Documents Needed:

- Driver's License/Photo ID

*If your ID/Driver's License does not have your current address listed, we will also need proof of address such as a utility bill, bank statement, or lease agreement*

- Proof of Household Income: Please provide your income, your spouse's income, your dependent's income and/or the income of anyone who claims you as a dependent.

*Examples of proof of income: paystubs, W-2s, 1040 tax form & Schedule C (for those who are self-employment), social security award letter, disability award letter*

- Most recent 1040 tax form

*This is needed if you are recertifying/applying to be a medical patient in order for you to be eligible to receive certain prescription medications*
File Upload

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Should be Empty:

	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless

	Not at all	Several days	More than half the days	Nearly every day
Trouble falling asleep or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling you are a failure or have let yourself or your family down
Trouble concentrating on things such as reading a book or watching TV
Moving or speaking so slowly or so quickly that other people have noticed
Thoughts you would be better off dead or want to hurt yourself in some way

Lackey Clinic Patient Application

Lackey Patient Application

Lackey Clinic Patient Application

Demographics

Lackey Clinic Patient Application

Lackey Clinic Patient Application

Lackey Clinic Patient Application

Lackey Clinic Patient Application