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Genesis Healthcare, Inc.
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New Patient Application
Annual Patient
GHC Annual Patient Application
Instructions
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Select GHC Office
Please select your GHC office
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Pee Dee Health Care
Genesis Healthcare Darlington (Behavioral Health)
Olanta Family Care
Lamar Family Care
Walterboro Family Care
Genesis Healthcare Florence
Lowcountry Pediatrics
Patient Information
Last Name
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First Name
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Middle Initial
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Social Security #
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Numbers only (example 123456789)
Address
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City
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State
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Zip
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Numbers only
Home Telephone
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Cell Phone
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If you do not have a cell phone, please enter: 000-000-0000
Date of Birth
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Age
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Email
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Yes! Sign me up for Genesis email updates
Yes
No
Consent to Call
Yes
No
Consent to Text
Yes
No
Gender
Male
Female
Female-to-Male/Transgender Male
Male-to-Female/Transgender Female
Gender Non-Conforming/Neither Male nor Female
Other
(Gender) Other
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Sexual Orientation
Bisexual
Lesbian/Gay/Homosexual
Straight/Heterosexual
Unknown
Rather Not Disclose
Other
(Sexual Orientation) Other
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Insured's Language
English
Spanish
Chinese
French
German
Italian
Sign Language
Other
(Insured's Language) Other
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Marital Status
Single
Married
Divorced
Widowed
Separated
Life Partner
Unknown
Race
African American/Black
White
Asian
American Indian/Alaska Native
Korean
Pacific Islander
Asian Indian
Chinese
Filipino
Japanese
Vietnamese
Samoan
Guamanian or Chamorro
Rather Not Answer
Other
(Race) Other
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Ethnicity
Hispanic/Latino
Non-Hispanic/Latino
Mexican
Cuban
Mexican American
Puerto Rican
Rather Not Answer
Other
(Ethnicity) Other
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Veteran Status
Yes
No
Decline
Homeless Status
Yes
No
Decline
Student
Yes, Full Time
Yes, Part Time
No
Public Housing
Yes
No
Decline
If (student) yes, Provide School Name
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Current Primary Care Provider
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Date of Last Visit with Current Provider
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Current Primary Care Provider
City
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Do you want to change current provider?
Yes
No
Current Primary Care Provider
State
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Current Primary Care Provider
Phone #
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Currently Treated by Home Health/SC House Calls/Hospice
Yes
No
Current Pharmacy
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Current Pharmacy
City
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Current Pharmacy
Phone
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Do you have a Provider Preference?
Yes
No
Requested Provider
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Emergency Contact (ages 19 and above)
Emergency Contact Name
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Emergency Contact Phone
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Emergency Contact Relationship
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GHC Reference and Board Section
How did you hear about Genesis Healthcare? Please select one:
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Referral
Current Patient
Social Media Advertisement
Newspaper Article
Community Event
If you selected 'Referral' for how you heard about Genesis Healthcare, please specify the Referral Source:
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Are you interested in serving on the Board of Directors for Genesis Healthcare?
Yes
No
Insurance
Primary Insurance
Primary Insurance
Insured’s Name (If other than patient):
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Primary Insurance
Insurance Company
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Primary Insurance
Address
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Primary Insurance
ID Number
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Primary Insurance
DOB
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Primary Insurance
Employer
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Secondary Insurance
Secondary Insurance
Insured's Name (If other than patient):
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Secondary Insurance
Insurance Company
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Secondary Insurance
Address
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Secondary Insurance
ID Number
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Secondary Insurance
DOB
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Secondary Insurance
Employer
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NARCOTIC ACKNOWLEDGMENT
Section 2
I (Print Name) acknowledge that it has been explained to me that Genesis Healthcare, Inc. does not provide chronic narcotic pain management. This includes the use of narcotic medication as well as other supplemental controlled substances. I understand and agree that I will be referred to another clinic for pain management by that facility’s physician.
Patient Signature/Patient Authorized Representative Signature (Sign below with your mouse or finger):
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*
Print Name
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Relationship to Patient if patient unable to sign
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ANSWERING MACHINE/VOICE MAIL MESSAGES
Section 3
There may be times when our office is not able to reach you by telephone. With your permission, we would like to be able to leave messages on your home answering machine/cell phone voice mail. To comply with strict legal standards, a written release will allow us to leave a message on your answering machine. By signing below, you are authorizing us to leave messages on your answering machine at the telephone number you have given us in your record.
Patient/Patient Authorized Representative Signature (Sign below with your mouse or finger):
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Patient Name (Print):
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Relationship to patient if Unable to Sign:
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HIPAA AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Section 4
Some patients prefer other individuals, especially family members, be allowed access to their medical information. To comply with strict legal standards, a written release is required to allow another person access to your medical records. This release grants permission to individual(s) listed below to: Make or confirm appointments, have access to x-ray and laboratory findings, pick up sample medications, be made aware of your diagnosis, prognosis, and treatment plans, and serve as your emergency contact. This permission applies to telephone and answering machine messages as well as other means of communication.
Patient’s Signature (Sign below with your mouse or finger):
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*
Patient Print:
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1. Designated Party:
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Telephone:
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Relationship:
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CONSENT FOR TREATMENT AND AUTHORIZATION
Section 5
I, the undersigned, do hereby authorize and consent to medical examinations, x-rays, blood tests, laboratory procedures, immunizations, therapeutic injections, invasive or surgical procedures and other medically appropriate services under the general or specific supervision of any member of the medical staff of Genesis Healthcare, Inc for the patient named on this form. It is understood that this authorization is given in advance of any specified diagnosis, treatment or care being required but it is given to provide authority and power to render care by providers of Genesis Healthcare, Inc. in the exercise of her/his best judgment that they may deem advisable. I understand that state law requires physicians to report certain communicable diseases to the Health Department. SC Code Ann. Sec 44-29-10. Regulation 61-20. I agree that if I leave a physician’s office against the advice of my physician(s) of Genesis Healthcare, Inc and its personnel, they are released from responsibility or liability for any injuries or damages which may result from leaving against medical advice. I authorize a physician of Genesis Healthcare, Inc to test me for HIV antibodies or tuberculosis when the doctor or any employees are exposed to body fluids in a manner which may transmit human immunodeficiency virus (HIV), or infection of tuberculosis. In the event of such an exposure, you will be deemed to have consented to such testing, and to have consented to the release of the test results to the person(s) who may have been exposed.
Patient/Patient Authorized Representative Signature (Sign below with your mouse or finger):
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*
Patient Name (Print):
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Relationship to Patient if Unable to Sign:
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AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Section 6
Please Fax Records to Attention:
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I authorize the use and disclosure of my individual health information as described below. I understand that the information I authorize a person or entity to receive may be re-disclosed and no longer protected by federal privacy regulations. (Note: S.C. Law prohibits the re-disclosure of mental health records).
Patient's Name:
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DOB
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Social Security #
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Numbers only (example 123456789)
MR#
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Person/Organization Disclosing the Information
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Person/Organization receiving the information (Select 'Yes' for all that apply):
Pee Dee Health Care
201 Cashua St Darlington, SC 29532 Phone: (843) 393-7452 Fax: (843) 393-6210
Yes
Genesis Healthcare Darlington (Behavioral Health)
115 Exchange St Darlington, SC 29532 Phone: (843) 393-9421 Fax: (843) 968-3473
Yes
Olanta Family Care
211 S Jones Rd Olanta, SC 29114 Phone: (843) 396-9730 Fax: (843) 396-9735
Yes
Lamar Family Care
301 W Main St Lamar, SC 29069 Phone: (843) 395-8400 Fax: (843) 395-8401
Yes
Walterboro Family Care
457 Spruce St Walterboro, SC 29488 Phone: (843) 781-7428 Fax: (843) 781-7429
Yes
Genesis Healthcare Florence
1523 Heritage Ln Florence SC, 29505 Phone: (843) 673-9992 Fax: (843) 673-9996
Yes
Lowcountry Pediatrics
99 Bridgetown Rd, Goose Creek, SC 29445 Phone: (843) 572-3300 Fax: (833) 771-2207
Yes
Information for treatment period:
From (Date):
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To (Date):
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Type(s):
Office Notes
Yes
Hospital Notes
Yes
Laboratory Test
Yes
Consults
Yes
Radiology Reports
Yes
Ancillary Testing Reports
Yes
Other (please specify)
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Purpose(s):
Insurance
Yes
Legal Investigation
Yes
Disability Evaluation
Yes
Continued Care
Yes
Purpose(s) If Other Specify
*
OR
OR
I may request my information be released to me to exercise my right to access and obtain a copy of my PHI.
Yes
No
I have read and understand this Authorization. I certify that I am the Patient listed above or a person authorized to permit release of records on the Patient's behalf. I hereby release Genesis Healthcare, Inc from any liability or damages arising in connection with or related to the use and/or disclosure of my protected health information pursuant to this Authorization.
Patient Signature (Sign below with your mouse or finger):
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Patient Name - Print
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Authorized Representative
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Relationship to Patient
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Telephone Number
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