Patient Registration: English

Please answer the following questions so we may better serve you:

In the last 2 years have you or anyone in your family worked in any type of agriculture (farm work) like: planting, picking, preparing the soil, packing house, driving a truck for any type of farm work, worked with animals?


In the last 2 years, have you or a member of your family lived away from home in order to work in any type of agriculture?


Have you or a family member stopped migrating to work in agriculture because of a disability?








COMPLETE THE FOLLOWING SECTIONS ONLY IF PATIENT IS A MINOR (NOT APPLICABLE FOR FAMILY PLANNING SERVICES)




RELEASE OF INFORMATION/FINANCIAL RESPONSIBILITY:
I hereby authorize AccelHealth to release any medical or other information needed to process all insurance claims.
I authorize payment of insurance benefits directly to AccelHealth. I agree that I am responsible for payments for services rendered, deductibles and coinsurance. I am aware that failure to pay may result in termination of the patient/clinic relationship.
A photocopy of this authorization shall be considered as valid as the original. This authorization will remain in effect until revoked by me in writing. By signing this form, I am saying that I understand what is written above and that I voluntarily ask for and consent to treatment.

THANK YOU FOR CHOOSING ACCELHEALTH!