Hope Health Clinic
1025 Sanibel Way, Suite E
LaGrange, Kentucky 40031
Phone: 502-225-6711
Hope Health Clinic is a community-wide ministry delivering and coordinating quality medical care in
a Christ-honoring environment to those who lack access to healthcare. So that we can serve all who
are in need we have established the following guidelines.
Please note:

Visits with medical providers are $10 (either debit/credit card or cash) and are expected at
the time of the appointment.
 We do not provide the following:
o Any type of scheduled medication
o Care for injuries sustained in an automobile accident
o We do not complete disability medical forms however, we will be glad to provide a
copy of your medical records to another provider, if requested.
o Care for workmen’s compensation injuries.
 We are offer care for those 4 years of age or older.
 We do not participate in private insurance including Medicaid or Medicare. However we are
glad to provide care for you for the $10 payment mentioned above.
 If labs are required as a part of your medical care we offer those labs here in the clinic. Labs
are provided at a low cost (generally our labs are $6, $7, $8 or $9 each).
 A patient is allowed a maximum of 3 “No-Show/No Calls. After 3 missed appointments in
which the patient failed to call in advance of the appointment, you will be unable to be seen
here for a period of 12 months. ALL APPOINTMENTS MUST BE CANCELLED AT LEAST
24 HOURS PRIOR TO THE APPOINTMENT TO AVOID NO CALL NO SHOW STATUS
We commit to treating you as a whole person, physically, mentally and spiritually and will offer
guidance and referrals to help you obtain optimum health. We expect our patients to be active
participants in improving and maintaining their health.
If you have questions regarding any of our policies, please feel free to ask to speak to me
personally.
Call ahead for an appointment time and bring the documents in this packet with you to your first
appointment.
Thank you for choosing Hope Health Clinic.
Janet Warren
Clinic Administrator
Patient Assessment Form 2/9/2016
Date:
Patient:
D.O.B.
Allergy:
Age:
Last ER Visit:
M
F
Last Hospital Visit:
Chief Complaint:
Physical Height Weight BMI
Exam
Temp B.P.
Pulse Resp. Smoke O2 Level Diabetic Pre-Diab. Gluc.
Read
Yes No Yes No
HPI
Medical Hx/Family/Social Hx recorded under medication list on the left side of file. Reviewed & Updated
ROS:
N
A
N
A
CONST:
Fever-Chills-Wt. Loss-Weakness
Musc/skel
Back pain-Joint pain-swelling
HEENT:
eyes d/c, acuity change-Hearing Loss-Earache-Ear Drainage-Nasal Drainage-Sore Throat
Breasts:
Pain-Lump-Discharge
Skin
Skin Lesions-Rash-Pruritus
Lungs:
Cough-Sputum-Wheezing
Psych
Anxiety-Depression-“Nerves”
Heart:
Chest pain-Palpitations-PND-Ortho
Neuro
Syncope-Dizziness-Focal Weakness
GI:
Nausea-Vomit in-Diarrhea-Pain-Melena-Dyspepsia
GU
Dysuria-Frequency-Urgency
Other:
PHYSICAL EXAM
NAD
Well Developed-Well Nourished
Alert
Non-Toxic
HEENT PERRLA-EOMI-DISC NORMAL
NECK SUPPLE-NO NODES-NO JVD-NO BRUIS-NOTHYROMEOALY
BREAST NO MASSES-NO DISCHARGE-SKIN NIPPLES/AREOLA NL
CHEST/LUNGS BS NL-NO ADENTITIOUS SOUNDS
HEART PMI NL-RRR-NO MURMUR-NO GALLOP
ABDOMEN SOFT-NT-NON-DIST-NO ORGANOMEGALY-BS
GU/RECTAL NL ADULT MALE/FEMALE-NO HERNIA-HEME NEG
BACK/MSK/EXT NO CVAT-CLUBBING-CYANOSIS-EDEMA-ROM NL
NEURO CN II-XII-INTACT-SENSORY INTACT-MOTOR NL-DTR NL/SYM
SKIN NO RASH-TURGOR NL
OTHER
PROCEDURES/LABS
ASSESSMENT:
PLAN:
SIGNATURE:
DISCUSSED SMOKING CESSATION:
Patient Assessment Form 2/9/2016
YES
RTO:
NO
Age-appropriate Behavior
Hope Health Clinic – Statement of Rights & Responsibilities
I. CONSENT TO TREATMENT
As a patient of Hope Health Clinic, I consent to any diagnostic and medical treatment my physician or other medical staff
members consider necessary for my course of treatment and health. I understand that treatment may involve risks, that
the practice of medicine is not an exact science, and that no promises, warranties, or guarantees have been made as to
the results obtained.
I understand that if I am undergoing a treatment which may require one or more visits that this consent may be used for
the entire course of treatment.
II. CONSENT TO RELEASE AND OBTAIN INFORMATION
I give Hope Health Clinic permission to release and/or obtain information from my medical record, or permit inspection of
such medical information, including but not limited to psychological/psychiatric and/or drug/alcohol related conditions,
communicable disease diagnosis and/or testing including the results for Human Immunodeficiency Virus Infection,
Hepatitis, or other blood-borne infectious disease for the purposes of treatment and health care operations, as more fully
described in the Notice of Privacy Practices.
Anonymity and confidentiality will be protected to the extent permitted by law, but absolute confidentiality cannot be
guaranteed. However, strict adherence to professional standards of confidentiality and the requirements of state and
federal law regarding protection of patient privacy will be maintained at all times.
III. PATIENT RESPONSIBILITIES
1. I will respectfully keep my appointment time to the best of my ability, and will notify Hope Health Clinic ahead of time if
I need to cancel my appointment. Failure to do so more than three (3) times will be sufficient cause for me to be denied
further appointments for a period of 12 months. I understand also that I will be denied further appointments and care if I
misrepresent any information or engage in any inappropriate and/or threatening behavior to any employee or volunteer
staff at Hope Health Clinic.
2. I understand if I am referred for care at a specialist or am in need medications available through pharmaceutical
assistance programs, I will bring the required financial documentation to the clinic in a timely manner so additional care or
medication may be provided to me.
IV. ACKNOWLEDGMENTS
1. I hereby certify that I have read and understand the contents of this Statement of Rights & Responsibilities, and
have voluntarily agreed to abide by these terms.
2. I acknowledge that I have received a copy of the Notice of Privacy Practices which explains how my protected
health information may be used and disclosed for treatment and health care operations.
________________________ ___/___/_______
Patient Signature
Date Signed
Patient Assessment Form 2/9/2016
PATIENT CONSENT FORM
Hope Health Clinic
Patient Consent for Use & Disclosure of Protected Health Information
I hereby give my consent for Hope Health Clinic to use and disclose protected health information (PHI) about me to
carry out treatment and health care operations (TPO). The Notice of Privacy Practices provided by Hope Health Clinic
describes such uses and disclosures more completely. I understand I may ask for a copy of this document.)
I have the right to review the Notice of Privacy Practices prior to signing this consent. Hope Health Clinic reserves
the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained
by forwarding a written request to Hope Health Clinic, 1025 Sanibel Way, LaGrange, Ky. 40031 or asking for a copy
in person.
With this consent, Hope Health Clinic may call my home or other alternative location and leave a message on voice
mail or in person in reference to any items which assist the practice in carrying out TPO, such as appointment
reminders, insurance items and any calls pertaining to my clinical care, including laboratory results, among others.
With this consent, Hope Health Clinic may mail to my home or other alternative location any items which assist the
practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked
“Personal and Confidential.”
With this consent, Hope Health Clinic may e-mail to my home or other alternative location any items which assist the
practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request
Hope Health Clinic restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to
my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to allow Hope Health Clinic to use and disclose my PHI to carry out TPO. I may
revoke my consent in writing except to the extent which the practice has already made disclosures in reliance upon
my prior consent. If I do not sign this consent, or later revoke it, Hope Health Clinic may decline to provide treatment
to me.
_____________________________________________________________________________________________
Signature of Patient or Legal Guardian
Print Patient’s Name
_____________________________________________________________________________________________
Date
Print Name of Legal Guardian, if applicable
Patient Assessment Form 2/9/2016