Patient Forms

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American Indian/Alaskan NativeAsianBlackDecline/Prefer not to sayMulti-racial/multi-culturalWhite

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Hispanic/LatinoNot Hispanic/LatinoDecline/Prefer not to say

Do you have medical insurance? (required)

Do you have dental insurance? (required)

FTCA and HIPAA Acknowledgement for New Patients

Notice of Limited Liability of FTCA Deemed Free Clinc Health Care Professionals

This is to notify you that under Federal law relating to the operation of free clinics, the Federal Tort Claims Act (FTCA), (See 28 USC §§ 1346, 2401 (b), 2671-80) provides the exclusive remedy for damage from personal injury, including dealth, resulting from the performance of medical, surgical, dental or related functions by any free clinic health care practitioner who the Department of Health and Human Services has deemed to be an employee of the Public Health service.

This FTCA medical malpractice coverage applies to deemed free clinic health care pratitioners who have provided a required or authorized service unter Title XIX of the Social Security Act (i.e., Medicaid program) at a free clinic site or through offiste programs or events carried out by the free clinic (See 42 USC § 233 (a), (o)).

The above Federal law and other State and Federal laws including the Federal Volunteer Protection Act of 1997 may cover certain free clinic health care professionals providing health care services to patients at this free clinic.

Health Insurance Portability and Accountability Act

All health care providers are required by law to inform you about how your medical information is exchanged among other health care providers and other health care entities.

By signing this form, you:

Acknowledge understanding of the FTCA program.

Acknowledge that you have access to information about the HIPAA, available at hrsa.gov.

Understand that all information regarding your insurance is true.

Appointment Contract and Treatment Authorization

Treatment Authorization

I hereby consent to the authorization of such medication and the performance of such treatment needed/necessary while a patient at Lake County Free Clinic.

I also consent to the release of such information regarding my case to any physician referrals deemed necessary of advisable while a patient at Lake County Free Clinic.

Patient Appointment Contract

LCFC requires that every patient annually reviews our policy about keeping and cancelling appointments. Your signature below indicates that you understand each line.

I will give at least 24 hours notice if I am unable to keep my scheduled appointment. Call 440-352-8686 to cancel an appointment. (You can also sign up for MyChart to send secure messages to LCFC electronically.)

If I do not provide 24 hours notice before cancelling my appointment, it will be considered a missed appointment (no-show appointment).

If I miss 2 appointments in 12 months I may not be able to reschedule for services at LCFC again for 6 months.

If I am not able ot be seen due to missed appointments, I will also be ineligible for prescription refills from LCFC.

If I miss 3 appointments in 12 months I may be permanently ineligible for prescription refills from LCFC.

It is my responsibility to keep my contact information current and I will update LCFC any time it changes.

I may be restricted from making appointments without being notified if I cannot be reached.

If I need an interpreter, it is my responsibility to have this arranged for my appointment. I understand my appointment may have to be rescheduled if no interpreter is present.

By signing this form, you:



Consent to the authorization of treatment and release of information as needed.

Understand and agree to the terms of the patient contract.