WELCOME TO NEW HORIZON FAMILY HEALTH SERVICES! Thank you for choosing NHFHS as your medical home! Please take a few minutes to read this new patient information before your visit. REGULAR BUSINESS HOURS: New Horizon Family Health Services operates on an appointment basis but provide services for sudden or acute illness (same day appointments for established patients only). Regular business hours vary by location as listed in the service location column. **All locations are closed on New Year’s Day, Martin Luther King, Jr.’s Birthday, Good Friday, Memorial Day, Independence Day, Labor Day, Thanksgiving Day (2 days), and Christmas (2 days). APPOINTMENTS: For appointments, call directly to most convenient location. Press 1 for English or 2 for Spanish, and then follow the prompts. Should you have an emergency after regular business hours, please call New Horizon Family Health Services and speak to the on-call nurse. CANCELLATIONS/RESCHEDULING APPOINTMENTS: WE ASK THAT YOU CALL THE OFFICE AT LEAST 24 HOURS PRIOR TO YOUR APPOINTMENT TO CANCEL/RESCHEDULE YOUR APPOINTMENT. This allows us to better serve you and our other patients. MEDICATIONS: Please bring all your medications with you to your appointment. PHARMACY HOURS: Press 3 for Pharmacy; on the last Thursday of each month, call for afternoon hours. Regular business hours vary by location as listed in the service location column. FEES/PAYMENTS: New Horizon Family Health Services accepts private insurance, Medicare, Medicaid, and offers sliding scale fee discount for those without insurance and who qualify. • Patients who receive Medicare or Medicaid benefits must bring their identification card each time they visit. • If you are on a sliding fee scale, the federal government requires that we have your financial status on file (recent income tax statement, 3 most recent paycheck stubs showing regular hours worked/gross income, or notarized document from employer stating salary per hour/week and number of hours worked). Charges depend on number of family members living in your home and family income before taxes. • Your copay is for the OFFICE VISIT ONLY; you are responsible for the charges for injections, procedures, labs, etc. • You must show a picture ID and alert us immediately of any changes (address, family status, or income). Failure to update information will result in having to pay full fee. Please have your social security number as well. SERVICE LOCATIONS Faris 975 West Faris Road Greenville, SC 29605 Phone: (864) 729-8330 8:00 AM- 9:00 PM Monday- Saturday PHARMACY HOURS: 8:00 AM- 9:00 PM Monday- Saturday Mallard 130 Mallard St., PO Box 287 Greenville, SC 29601 Phone: (864)233-1534 8:00 AM- 8:00 PM Monday- Thursday 8:00 AM- 5:00 PM Friday PHARMACY HOURS: 8:00 AM- 6:00 PM Monday- Thursday 8:00 AM- 5:00 PM Friday Travelers Rest 1588 Geer Hwy., PO Box 1370 Travelers Rest, SC 29690 Phone: (864) 836-1109 8:00 AM- 8:00 PM Monday, Wednesday 8:00 AM- 5:00 PM Tues, Thurs, Friday PHARMACY HOURS: 8:00 AM- 12:00 PM , 1:30 PM- 5:00 PM M-F but closed daily for lunch 12-1:30 PM Greer 111-A Berry Avenue Greer, SC 29651 Phone: (864) 801-2035 8:00 AM- 5:00 PM Mon, Wed, Friday 8:00 AM- 8:00 PM Tuesday, Thursday PHARMACY HOURS: 8:00 AM- 12:00 PM, 1:30- 5:00 PM M-F but closed daily for lunch 12-1:30 PM New Horizon Family Dental Care 1 Memorial Medical Drive Greenville, SC 29605 Phone: (864) 351-2400 8:00 AM- 5:00 PM Mon, Wed, Friday 8:00 AM- 7:00 PM Tuesday, Thursday Health Care for the Homeless Mobile Unit 130 Mallard St., PO Box 287 Greenville, SC 29601 Monday- Friday
Transcript
WELCOME TO NEW HORIZON FAMILY HEALTH SERVICES!
Thank you for choosing NHFHS as your medical home!
Please take a few minutes to read this new patient information before your visit.
REGULAR BUSINESS HOURS:
New Horizon Family Health Services operates on an appointment basis but
provide services for sudden or acute illness (same day appointments for
established patients only).
Regular business hours vary by location as listed in the service location column.
**All locations are closed on New Year’s Day, Martin Luther King, Jr.’s
Birthday, Good Friday, Memorial Day, Independence Day, Labor Day,
Thanksgiving Day (2 days), and Christmas (2 days).
APPOINTMENTS:
For appointments, call directly to most convenient location. Press 1 for English
or 2 for Spanish, and then follow the prompts.
Should you have an emergency after regular business hours, please call New
Horizon Family Health Services and speak to the on-call nurse.
CANCELLATIONS/RESCHEDULING APPOINTMENTS:
WE ASK THAT YOU CALL THE OFFICE AT LEAST 24 HOURS PRIOR
TO YOUR APPOINTMENT TO CANCEL/RESCHEDULE YOUR
APPOINTMENT. This allows us to better serve you and our other patients.
MEDICATIONS:
Please bring all your medications with you to your appointment.
PHARMACY HOURS:
Press 3 for Pharmacy; on the last Thursday of each month, call for
afternoon hours. Regular business hours vary by location as listed in the service
location column.
FEES/PAYMENTS:
New Horizon Family Health Services accepts private insurance, Medicare,
Medicaid, and offers sliding scale fee discount for those without insurance and
who qualify.
• Patients who receive Medicare or Medicaid benefits must bring their
identification card each time they visit.
• If you are on a sliding fee scale, the federal government requires that
we have your financial status on file (recent income tax statement, 3 most
atus of individonsible for hisponsible for coown), treatme
ems that arise
n decisions inv
right to consurmitted by law
ent has the rigndered.
ules and regu
responsible b
o the best of hhospitalizatio
he treatment p
atment is refu
l obligations i
ules and regul
erate of the rigoking and eati
___________
Dental CareDrive
DERevised:
Family Dental
hts of human
relationships
tics when rece
mes and unde
informationa
center practic
duals providin/her care. oordinating hi
ent and any kn
e during an of
volving his/he
lt with a specw. ght to request
lations applic
behavior on th
his/her knowlons, medicatio
plan
used or if the
ncurred in
lations affecti
ghts of other ing in the cen
___________
EN‐01 08 07
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ose a dentistd with you if txpect answers
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s
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t instructions ng treatment ly information
De
comfortable you ask questderstand.
out the medicpplements likeread the labew to use it. If
sk your dentiit take? Wha
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ental‐02 SpanishRev. 10.201
talking tions
cines that e vitamins el when you
the
st and at will nts if you exactly
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__________
__________
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appointmetment. If yoed to wait u
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__________
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PORTANTamily Heal
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tal Care
rive
5
EN‐01 08 07
ied
D.
Date: ___
Name: __
FI
Date of Bi
Race: (Che
[ ] Black/A
[ ] Caucas
[ ] Asian
[ ] Native
[ ] Other r
[ ] Choose
Please che
[ ] Employ
[ ] Unemp
[ ] Self‐em
[ ] Vetera
[ ] Migran
[ ] Full‐tim
Gender Id
[ ] Male
[ ] Female
[ ] Transge Female[ ] Transge Male‐t[ ] Choose
___________
____________
IRST
irth: _______
eck one)
African Ameri
sian/White
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race
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____________
___________
MIDDLE
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ican
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pply:
[ ] H
[ ] P
[ ] R
[ ] P
[ ] L
[ ] D
ck one)
[ ] Gender q
[ ] Other
e/
ose
NEW H
______
____________
LAST
Married Stat
Homebound
Part‐time stu
Retired
Public housin
Live on Street
Disabled
queer
ORIZON F
Pati
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___________
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us: ________
Ethn
[ ] La
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FAMILY HE
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al Security No
____________
FIX P
_____ Former
nicity: (Check
atino/Hispani
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hose not to d
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chool based h
ve with paren
ve in homele
gricultural wo
hoose not to
ual Orientatio
traight or het
esbian, gay or
isexual
on’t know
omething else
hoose not to
EALTH SE
ation Form
o.: _________
___________
PREFERRED N
r Last Name:
One)
ic
n‐Hispanic
disclose
___________
health center
nts/friends
ss shelter
orker
disclose
on: (Check on
erosexual
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DERevised:
ERVICES, I
___________
___________
AME
___________
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e)
l
EN‐06 08 07
NC
_____
_____
____
Reaso
Name Date o Social
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□ M
Please
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GUAR
Social
Name
Date o
Addre
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Insure
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*
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Full-Time Studen
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ated Monthly H
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of Birth: ______
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ance Company: _
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oyer Name: ____
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sit: ___________
___________RST
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ber: __________
ck one) □ Bla
□ Other □
apply: □ Empl
nt □ School b
ts/Friends □
______________EET/PO BOX
_________ ME
______________
______________
ousehold Incom
ORMATION (I
_____________
_____________RST
__________ Rac
____________REET/PO BOX
________ E
RMATION (Pl
______________
th: ___________
____________ STREET/ PO BO
_____________
____________ STREET/PO BO
porting purpose
NEW HO
_____________
____________ MIDDLE
Sex: Male
______________
ack/African Ame
□ Refuse
loyed □ Self-e
based health cent
Agricultural wo
______________
_______
______________
______________
me: ___________
If different from
______________
______________
ce: ___________
___________
_
lease provide a c
_____________
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______________
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es only. To appl
ORIZON FAPatient Regist
______________
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______________
erican □ Cauc
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employed □ Uter □ Homeb
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_____________CITY
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m patient):
______________
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____________ CITY
___________ MOBILE
copy of all insur
_________ Na
Security No: __
____________ CITY
_______ Phone:
____________ CITY
ly for Sliding Fe
AMILY DENtration Form
_________Date:
___________AST
Marital Status: _
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casian/White □Language: _____
Unemployed □ound □ Publ
ant □ Refuse
______________ STATE
_
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onship: _______
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_____________
tatus: ________
___________ STATE
_________ E
rance cards):
ame of Insured: _
______________
___________ STA
_____________
___________ STA
ee Discount you
NTAL CARE
: _____________
____________ SUFFIX
_____________
□ Asian □ Na
_____________
Disabled □
lic Housing □e
______________ ZIP C
_____________ WORK
_____________
ld Size: _______
______________ LA
________ Sex:
___________E
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_____________
_______ Relatio
___________ATE
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u will need to co
____________Ti
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ative American
______________
Retired □ Ve
Live in Homele
_____________CODE
_______ Ag
Phone: _______
______________
______________AST
Male
____________ ZIP CODE
____________ WORK
______________
onship to Patient
____________ ZIP COD
_____________
____________ ZIP COD
omplete the slid
ime: __________
____________REFERRED NAM
name: _______
□ Latino/Hisp
______________
eteran □ Part-
ess Shelter □
______________ COUNTY
ge: __________
______________
______________
_____________ SU
Female
___________ COU
____
_____________
: ____________
___________DE
______________
___________DE
ding fee applicat D
_____________
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______________
panic
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-time Student
Live on street
______________
_____
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_____
_____________UFFIX
__________ UNTY
____________
___________________________
_________
____________
_________
tion form** DENTAL/10.15
_
_
_
_
Date of la
Have you
Have you
If so, list d
________
________
Date of la
Are you p
Are you ta
Medicatio
________
________
________
________
*List any a
Are you a
st visit to a D
ever had diff
ever been ho
date and reas
____________
____________
st physical ex
presently unde
aking any me
ons:
____________
____________
____________
____________
additional me
llergic to:
Dentist ______
ficulties assoc
ospitalized in
son: ________
___________
___________
xamination __
er the care of
dications?
___________
___________
___________
___________
edications on
De
Pen
Asp
Oth
___
Do
Are
Hav
If y
If n
DENTAL HEA
___________
ciated with de
the last three
___________
____________
____________
___________
f a physician?
___
___
___
___
the back
ntal Anesthet
nicillin or oth
pirin
her Drugs (Lis
___________
you smoke o
e you on bloo
ve you been t
yes, would yo
no, would you
ALTH HISTORY
____________
ental treatme
e years?
____________
___________
___________
_____
?
How
____
____
____
____
tics
er Antibiotics
st) _________
____________
or chew Tobac
od thinners an
tested for HIV
u like the test
u like to be te
NAME___
CHART # _
DOB ____
DATE ___
Y PART I
_______
ent?
___________
___________
___________
w often do you
___________
___________
___________
___________
s
___________
___________
cco?
nd/or aspirin?
V/AIDS?
t redone?
ested?
___________
___________
___________
____________
Yes __
Yes __
___________
____________
____________
Yes __
Yes __
u take the me
____________
____________
____________
____________
Yes __
Yes __
Yes __
____________
____________
Yes __
? Yes __
Yes __
Yes __
Yes __
DERevised:
____________
___________
____________
___________
___ No ____
___ No ____
____________
___________
___________
___ No____
___ No____
edications?
___________
___________
___________
___________
___ No ____
___ No ____
___ No ____
___________
___________
___ No ____
___ No ____
___ No ____
___ No ____
___ No ____
EN‐06 08 07
____
_____
____
____
_____
_____
_____
_____
_____
_____
_____
____
____
Rheumatic F
Stroke or Cir
Heart Valve
Angina (Che
Heart Troub
Mitral Valve
High Blood
Heart Murm
Stomach Ulc
Gland Proble
Kidney Prob
Glaucoma
Venereal Dis
Fever Blister
Blood Disord
bleeding, Hem
Fainting or D
Pain or Nois
Thyroid Prob
Any teeth lo
Substance A
Frequent He
INDICATE SHOULD K__________ To the best odiagnostic prprocedures areleasing inf __________Patient, Pare __________Dentist Sign
Women
ILLNESS
Fever or Rheuma
rculative Problem
Problems/Surge
est Pain upon Ex
le/Congestive H
e Prolapse
Pressure
mur
cers
ems
blems/Renal Fail
sease
rs or Cold Sores
ders (i.e. Anemia,
mophilia, Leukem
Dizziness
se in Jaw
blems
ose, sensitive
Abuse
eadaches
ANY DISEASEKNOW ABOUT:______________
of my knowledgerocedures and teagreed to be neceformation to my
______________ent or Guardian S
______________nature
:
D
S
atic Heart Diseas
ms
ery
xertion)
Heart Failure
lure
, Prolonged
mia)
E CONDITION, _____________
______________
e, the provided mests that may be pessary or advisabinsurance comp
______________Signature
______________
Are you preg
DENTAL HEA
YES
se
OR PROBLEM____________________________
medical and denprescribed. In adble, including thany.
_________
_________
Name__
Chart #_
DOB__
DATE_
gnant? __
LTH HISTORY
NO
Shortnes
Arthritis
Artificia
Diabetes
Hepatiti
Swelling
Lupus
Allergie
Seizures
AIDS/H
Liver Di
Tubercu
Cancer o
Sinus Tr
Yellow J
Blood T
Gout
Alcoholi
Emotion
Asthma/
Sickle C
MS NOT LISTED___________________________
tal history is corddition, I consenhe use of oral sed
______ Date
______ Date
___________
___________
____________
____________
_______Yes
Y PART II
ILLNE
ss of Breath
s
al Joints/Artificia
s
s
g Ankles
es
s/Epilepsy
HIV Positive
isease
ulosis
or Tumors
rouble
Jaundice
Transfusion in pa
ism
nal Disorders
/Emphysema
Cell Anemia
D ABOVE THA____________________________
rrect. I consent tnt to the performdatives or local a
______________
______________
____________
___________
___________
___________
________
ESS
al Heart Valves
ast 5 years
AT YOU THINK____________________________
o such examinatming of the dentaanesthetic and in
______________
______________
Revi
___________
____________
____________
___________
_No
YES
K THE DENTIST_________ _________
tions, x-rays, andl and oral surger
ndicated photos,
_________
_________
DEN-07 ised: 10/15
____
____
____
_____
NO
T
d ry and
SLIDING FEE DISCOUNT PROGRAM
Acceptable documents for sliding fee application:
Three most recent consecutive paycheck stubs o No older than 30 days
Use GROSS pay o If it is someone that receives tips, combine hourly pay and tips
GOOD FOR 12 MONTHS Social Security determination letter or bank statement, if it is direct deposit
(the deposit will say US Treasury) GOOD FOR 12 MONTHS
Unemployment determination letter o Pay code will only be valid for 3 months o DO NOT use the one that has “potential” benefit amount
Letter from Employer o On letterhead, notarized and DATED o Must state gross income
GOOD FOR 12 MONTHS Proof of court ordered child support and/or alimony or;
GOOD FOR 12 MONTHS Filed income taxes (previous) year, if they are self-employed us the gross amount on
Schedule C forms or; Gross amount on 1040 or; W2’s
GOOD FOR 12 MONTHS
Designation % Poverty Discount
% Nominal
Fee Point of Service Payment
A 0‐100% 100% $20.00
B 101‐120% 80% $30.00
C 121‐130% 70% $39.00
D 131‐140% 60% $40.00
E 141‐150% 50% $59.00
F 151‐160% 40% $69.00
G 161‐170% 30% $80.00
H 171‐180% 20% $88.00
I 181‐200% 10% $90.00
200% & Above 0%
$97.50 visit could cost up to $150.00
‘B‐I’ Point of Service payment is only for the
office visit. It doesn’t include labs or tests
performed.
Name __
Address
City ____
Phone __
Marital S
Social Se
Family M
1. _____
2. _____
3. _____
4. _____
5. _____
6. _____
Income I
Employe
Head Of
Spouse
Other
Total Mo
I certify t
permissi
have a ch
Signature
Verified
___________
__________
__________
__________
Status: Mar
ecurity Numb
Members
__________
__________
__________
__________
__________
__________
nformation
er_________
Household
_
_
onthly House
that the abo
on to New H
hange in my
e: ________
by: _______
Slid
__________
___________
__________
___________
rried _____
ber _______
__________
__________
__________
__________
__________
__________
:
___________
__________
__________
__________
ehold Incom
ove informat
Horizon Fam
y financial st
___________
___________
ing Fee App
___________
__________
___________
_______
Single _____
___________
Relatio
______
______
______
______
______
______
__________
___________
___________
___________
me ________
tion is corre
mily Health S
tatus, I will n
__________
__________
plication/Rec
__________
___________
__State ___
_ Separated
__________
onship
___________
___________
___________
___________
___________
___________
____ Work P
________
________
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