CPN HEALTH SERVICES
MEDICAID SCREENING
MRN #
Patient's Name:
{{medicaid.Name}}
Phone #
{{medicaid.Phone}}
Address:
{{medicaid.Address}}
City
{{medicaid.City}}
Zip
{{medicaid.Zip}}
Mark all Y or N that apply:
YN
Pregnant
YN
Minor dependent children in the home (under 19).
{{medicaid.DependentChildrenCount}}
How Many?
YN
Between the age of 19-64.
NY
Single
YN
Married
YN
Are you 65 or older
YN
Disabled by Social Security Standards.
What is the start date of disability?
{{medicaid.DateDisabilityStart | date}}
YN
Disabled and receiving SSI
YN
Have you applied for Disability?
Date of application:
{{medicaid.DateDisabilityApplied | date}}
YN
Do you have any catastrophic illnesses, such as TB or AIDS?
What is your income?
{{medicaid.Income | currency}}
If married, Spouse's income?
{{medicaid.SpouseIncome | currency}}
If child, Mother's income?
{{medicaid.MotherIncome | currency}}
Father's income?
{{medicaid.FatherIncome | currency}}
What is family size?
{{medicaid.FamilySize}}
*for office use only
Approved
Denied
Does patient categorically relate?
YES
NO
Are they within income guidelines?
YES
NO
Medicaid #:
Effective Date:
Must apply at OKDHS:
ABD
TANF
Child Custody
Notes:
Denial Reason:
Signature of
patient or parent:
Date:
Signature of
CPN Employee:
Date:
CPN HEALTH SERVICES
ADULT INTAKE FORM
PATIENT INFORMATION
{{intake.LastName}}
{{intake.FirstName}}
{{intake.MiddleName}}
{{intake.MaidenName}}
Last Name
First Name
Middle Name
Maiden Name
{{intake.DateBirth | date : 'MM/dd/yyyy'}}
{{intake.BirthCityState}}
{{intake.Gender}}
{{intake.SSN}}
Date of Birth
Birth City, State
Sex
SSN
{{intake.PrimaryPhoneNumber}}
{{intake.SecondaryPhoneNumber}}
{{intake.WorkPhoneNumber}}
Primary Phone Number
Secondary Phone Number
Work Phone Number
{{intake.MailingAddress}}
{{intake.MailingCityState}}
{{intake.MailingZipCode}}
Mailing Address
City, State
Zip Code
{{intake.PhysicalAddress}}
{{intake.PhysicalCityState}}
{{intake.PhysicalZipCode}}
Physical Location of Home (if different than mailing)
City, State
Zip Code
{{intake.EmailAddress}}
Y
N
Do you have internet access?
Email
If Yes, where?
{{intake.InternetAccess}}
{{intake.MaritalStatus}}
{{intake.Ethnicity}}
{{intake.Race}}
{{intake.PrimaryLanguage}}
Marital Status
Ethnicity
Race
Primary Language
Y
N
Are you a migrant worker?
Y
N
Are you a currently homeless?
EMPLOYER IFORMATION
Y
N
Are you an employee of CPN?
{{intake.EmployerName}}
{{intake.EmployerAddress}}
{{intake.EmployerPhoneNumber}}
Employer Name
Address
Phone
{{intake.SpouseEmployerName}}
{{intake.SpouseEmployerAddress}}
{{intake.SpouseEmployerPhoneNumber}}
Spouse's Employer Name
Address
Phone
TRIBAL AFFILIATION
Y
N
Are you a member/citizen of a federally recognized tribe?
Y
N
Do you have a Tribal ID or Certification of Indian Blood Card (CBID)?
If yes, what is the name of the federally recognized tribe?
{{intake.Tribe}}
EMERGENCY CONTACT/ NEXT OF KIN
EMERGENCY CONTACT
{{intake.EmergencyLastName}}
{{intake.EmergencyFirstName}}
{{intake.EmergencyRelationship}}
{{intake.EmergencyPhoneNumber}}
Last Name
First Name
Relationship
Phone Number
{{intake.EmergencyMailingAddress}}
{{intake.EmergencyCityState}}
{{intake.EmergencyZipCode}}
Mailing Address
City, State
Zip Code
NEXT OF KIN
{{intake.NextOfKinLastName}}
{{intake.NextOfKinFirstName}}
{{intake.NextOfKinRelationship}}
{{intake.NextOfKinPhoneNumber}}
Last Name
First Name
Relationship
Phone Number
{{intake.NextOfKinMailingAddress}}
{{intake.NextOfKinCityState}}
{{intake.NextOfKinZipCode}}
Mailing Address
City, State
Zip Code
MILITARY SERVICE
Y
N
Are you currently or have you in the past served in the United States military?
If yes, which branch?
{{intake.Branch}}
Dates of Service
{{intake.DatesOfService}}
Y
N
Are you currently active duty?
MEDICAL INSURANCE
Y
N
Do you have medical insurance (including Medicare, Medicaid, or Private Insurance)?
If yes, please complete the attached Private Insurance form.
If no, patients will be required to meet with the Citizen Potawatomi Nation Health Services Benefits Coodinator prior to or at the date of the patient's first clinic visit.
Failure to provide medical insurance (Medicare, Medicaid, private insurance, etc.) could result in suspension or denial of
services. Funds collected from third party resources are used improve and expand medical services at Citizen Potawatomi
Nation. Native Americans are not billed for any remaining balances, following insurance payment.
CLINIC LOCATION PREFERENCE/ SERVICES REQUESTED
PREFERRED CLINIC LOCATION
East Clinic
2307 E. Gordon Cooper Drive
Shawnee, OK 74804
(405) 273-5236
West Clinic
781 Grand Casino Blvd.
Shawnee, OK 74804
(405) 964-5770
Is there a specific need or reason for which you would like to be seen?
{{intake.VisitReason}}
CLINICAL SERVICES REQUESTED
Y
N
Medical
Y
N
Dental *
Y
N
Optometry
Y
N
Behavioral Health *
* Please note that these services require an additional application. Our team is happy to provide these forms to you
upon request.
CPN HEALTH SERVICES
INSURANCE DISCLOSURE FORM
PART I - PATIENT INFORMATION
{{intake.LastName}}
{{intake.FirstName}}
{{intake.MiddleName}}
{{intake.MaidenName}}
Last Name
First Name
Middle Name
Maiden Name
{{intake.DateBirth | date : 'MM/dd/yyyy'}}
{{intake.SSN}}
{{intake.Gender}}
Date of Birth
SSN
Sex
{{intake.PrimaryPhoneNumber}}
{{intake.SecondaryPhoneNumber}}
{{intake.WorkPhoneNumber}}
Primary Phone Number
Secondary Phone Number
Work Phone Number
{{intake.MailingAddress}}
{{intake.MailingCityState}}
{{intake.MailingZipCode}}
Mailing Address
City, State
Zip Code
{{intake.Race}}
Race
If you are Native, please specify the tribe in which you are enrolled:
{{intake.Tribe}}
Y
N
Do you have Medicare?
If yes, what is the Medicare ID#?
{{intake.MedicareID}}
Y
N
Do you have Medicaid?
If yes, what is the Medicaid ID#?
{{intake.MedicaidID}}
Y
N
Do you have Private Insurance?
Y
N
Vision Benefits?
Y
N
Dental Benefits?
Please verify the information above is correct. If the information provided is accurate, sign and date the form below.
If you are insured, please provide additional information on Part II (located on the back page).
Disclaimer: If you or your dependent have health insurance coverage and fail to advise CPNHS of the coverage
or you are eligible for coverage but refuse to apply, CPNHS may impose sanctions involving suspension or
withdrawal of your eligibility to receive services within our health system.
Patient Signature
Date
Parent/Guardian Signature
Date
Relationship to Patient
PART II - PRIVATE INSURANCE INFORMATION
Note: In Part II, provide information on the policy holder of the patient’s health insurance policy
{{intake.PolicyHolderLastName}}
{{intake.PolicyHolderFirstName}}
{{intake.PolicyHolderRelationship}}
Last Name of Policyholder
First Name of Policyholder
Relationship to Patient
{{intake.PolicyHolderDateBirth | date}}
{{intake.PolicyHolderSSN}}
{{intake.PolicyHolderPhoneNumber}}
Date of Birth
SSN
Phone Number
{{intake.PolicyHolderMailingAddress}}
{{intake.PolicyHolderMailingCityState}}
{{intake.PolicyHolderMailingZipCode}}
Mailing Address
City, State
Zip Code
{{intake.InsuranceCompany}}
{{intake.InsuranceEffectiveDate}}
Name of Insurance Company
Effective Date
{{intake.PolicyHolderEmployer}}
{{intake.PolicyHolderEmployerPhoneNumber}}
Policyholder's Employer
Phone Number
Policyholder's Employment Status
{{intake.PolicyHolderEmployStatus}}
Provide information below on other family members covered by this insurance policy:
| Patient's Name | Relationship to Policyholder | Date of Birth | Chart# (if known) | Effective Date |
|---|---|---|---|---|
{{item.Name}} |
{{item.Relationship}} |
{{item.DateBirth}} |
{{item.Chart}} |
{{item.EffectiveDate}} |
Please provide FRONT and BACK copies of insurance cards. Make sure application is complete and all
necessary documents are attached.
Patient Signature
Date
Parent/Guardian Signature
Date
Relationship to Patient
CPN HEALTH SERVICES
INSURANCE DISCLOSURE FORM
{{intake.FirstName}} {{intake.MiddleName}} {{intake.LastName}}
{{today | date : 'MM/dd/yyyy'}}
Name
Date
{{intake.DateBirth | date : 'MM/dd/yyyy'}}
{{intake.Gender}}
{{intake.Height}}
{{intake.Weight}}
Date of Birth
Sex
Height
Weight
Past Medical History
Y
N
Allergy to Anesthesia
Y
N
High Blood Pressure
Y
N
Anemia/Blood Disorder
Y
N
HIV/AIDS
Y
N
Arthritis
- Type: {{intake.ArthritisType}}
Y
N
Incontinenance/Urinary Problems
Y
N
Blood Vessel Disorder
Y
N
Kidney Disease/Stones
Y
N
Blurred Vision
Y
N
Liver problems/Hepatitis
Y
N
Breathing Problem
Y
N
Neurological Problems
Y
N
Cancer
- Type: {{intake.CancerType}}
Y
N
Osteoporosis
Y
N
COPD/Asthma
Y
N
Prostate Problems
Y
N
Depression
Y
N
Seziures/Frequent Headaches
Y
N
Diabetes
Y
N
Sleep Apnea/CPAP
Y
N
Drug/Alcohol Addiction
Y
N
Stomach Ulcers/Bloody Stools
Y
N
Ear, Nose, Throat Problems
Y
N
Stroke/Blood Clots
Y
N
Gastro-intestinal Reflux
Y
N
Thyroid Disease
Y
N
Heart Disease
Y
N
Tuberculosis
Y
N
Heart Failure
Y
N
Other
: {{intake.OtherHistory}}
Past Surgical History
| Year | Procedure | Surgeon | Location |
|---|---|---|---|
{{item.Year}} |
{{item.Procedure}} |
{{item.Surgeon}} |
{{item.Location}} |
Immunizations
{{intake.LastFluShot}}
{{intake.LastPneumonia}}
{{intake.LastTetanus}}
Last Flu Shot
Last Pneumonia Vaccine
Last Tetanus/Diphtheria
Y
N
If patient is less than 18 years old: Are Immunizations up to date?
Current Medications
| Name | Dose | Frequency |
|---|---|---|
{{item.Name}} |
{{item.Dose}} |
{{item.Frequency}} |
Allergies to Medications, Foods, Latex, or Other Substances
{{intake.Allergies}}
Family Medical History
Y
N
Arthritis
Y
N
Asthma
Y
N
Bleeding Problems
Y
N
Cancer
- Type: {{intake.FamilyCancerType}}
Y
N
Diabetes
Y
N
Heart Disease
Y
N
High Blood Pressure
Y
N
Kidney Disease
Y
N
Mental Illness/Depression
Y
N
Neurological Problems
Y
N
Osteporosis
Y
N
Seizures
Y
N
Stroke
Social History
{{intake.MaritalStatus}}
{{intake.Tobacco}}
{{intake.Alcohol}}
Marital Status
Tobacco Use
Alcohol Use
Y
N
Have you ever injected drugs into your veins?
Y
N
Do you use any illegal drugs?
Y
N
Do you have a living will indicating your advanced directive for health care?
Y
N
Do you want information about a living will?
CPN HEALTH SERVICES
PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
By signing these consents, I understand that it is good for one year from date of signature. I may
revoke this consent at any time by submitting a written revocation notice. I can not hold the CPNHS
liable for use and disclosures made prior to my revocation. If I do not sign this consent statement, the
CPNHS may decline to treat me.
I, ________________________________________________, freely give my consent to the Citizen Potawatomi Health Services
(CPNHS) to disclose protected health information about me in order to facilitate my treatment, perform billing
and payment functions, and accomplish other healthcare operations. I have been given the opportunity to read
and have explained to me the CPNHS Notice of Privacy Practices prior to signing this consent. I understand
that the CPNHS has the right to revise its Notice of Privacy Practices, and that I can obtain a copy of the current
Notice by sending a written request to the Privacy Officer, 2307 S. Gordon Cooper Dr., Shawnee, OK 74801.
I freely give consent to CPNHS employees to call my home or other designated locations and to leave
messages on voice mail or in person concerning items and topics which might assist the CPNHS performing
treatment, payment, and other healthcare operations. I include in this consent statement, appointment reminders
and calls pertaining to my care and treatment, laboratory, and X-ray results. I give consent to CPNHS to mail
items to my home or other addresses designated by me, items dealing with my treatment, payment for services
rendered to me, and other healthcare operations as long as they are marked “Confidential” and addressed to me.
I give consent to the CPNHS to notify me through home and/or mobile voice mail, mobile text messages
or by email designated by me which will assist the CPNHS in performing treatment, payment and other
healthcare operations.
I understand that I have the right to issue restrictions on the way the CPNHS uses and discloses my
protected health information and I know that the CPNHS is not required to agree to my restrictions. If it does
agree, it is bound by the agreement to observe my restrictions.
By signing this form, I give my consent to the CPNHS to use and disclose my protected health
information for the purposes of treating me, for obtaining payment for services rendered to me, and for
conducting other healthcare operations related to my care.
{{intake.FirstName}} {{intake.LastName}}
{{intake.DateBirth | date : 'MM/dd/yyyy'}}
Signature of Patient or Personal Representative/Date
Printed Name of Patient
Patient’s Date of Birth
Print name of signer if different than patient
Relationship to patient
CONSENT FOR TREATMENT AND ASSIGNMENT OF BENEFITS
I voluntarily submit to the treatment and diagnostic testing deemed necessary by my CPNHS provider for me or the minor
child named below to whom I am parent, medical surrogate, or personal representative. I understand that treatment may include, but
not limited to testing for diseases such as HIV, hepatitis, syphilis, or gonorrhea.
I authorize payment of insurance benefits to be paid directly to CPNHS for services provided by CPNHS providers, and by
executing the Patient Consent for Use and Disclosure of PHI above, I give consent for the use and disclosure of private health
information for the purposes of securing payment of benefits. A photocopy of this document has the same validity and full force as
the original.
{{intake.FirstName}} {{intake.LastName}}
{{intake.DateBirth | date : 'MM/dd/yyyy'}}
Signature of Patient or Personal Representative/Date
Printed Name of Patient
Patient’s Date of Birth
CPN HEALTH SERVICES
LIMITED CONFIDENTIALITY CLAUSE
CPNHS Special notice for CPN Employees and patients who are related to or in some other way affiliated with a/an
CPN Employee(s):
While CPNHS strives to maintain the upmost confidentiality and minimize conflicts of interest when it comes to all
medical and behavioral health concerns; there are times when CPNHS treatment providers and employees other
than your primary treatment provider will be involved in your medical care and/or have access to your medical
records including behavioral health notes. There may be situations where your information could be viewed
and/or acted upon by someone you are related to or otherwise affiliated with. This is especially true if you are a
CPN tribal member due to CPNHS Governing Board’s dual mandate of serving CPN tribal members as patients and
employing qualified CPN tribal members in medical professional and support staff roles. This could potentially
present conflicts of interest for you and/or the person viewing/acting on your information. There may be
situations where providers and staff will need to act on that information to provide timely medical standard of care
to a patient who is a family member or co-worker. There may be times where acting is not felt to be appropriate by
the provider and assistance from another colleague is requested. There may be situations where the conflict of
interest is large enough that it prohibits long term continuation of care with your provider or accessibility to
certain CPN clinics. If a conflict such as this arises you will be provided with appropriate referral options. If you
have questions or concerns about this please bring those up to your provider at the beginning of your
appointment. By signing below you indicate your understanding of the limits of confidentiality.
{{intake.FirstName}} {{intake.LastName}}
{{intake.DateBirth | date : 'MM/dd/yyyy'}}
Signature of Patient or Personal Representative/Date
Printed Name of Patient
Patient’s Date of Birth
Print name of signer if different than patient
Relationship to patient
CPN HEALTH SERVICES
ACKNOWLEDGEMENT OF PRIVACY PRACTICES NOTICE RECEIPT
Offical Use: Chart # ________________________________________________
I have received and read a copy of the Citizen Potawatomi Nation Health Services Privacy Practices
Notice outlining how my personal health information will be used and safeguarded, and my rights
regarding the protection of my personal data.
I understand that the CPNHS Privacy Practices Notice was provided to me in accordance with the
provisions of the Health Insurance Portability and Accountability Act of 1996, and that if I have any
questions about the content of the Notice I can contact the CPNHS Privacy Officer by mail at 2307 S.
Gordon Cooper Dr, Shawnee, Ok 74801.
I have been told that if I decline to sign this acknowledgement, my refusal will have no bearing on my
eligibility for treatment at the Citizen Potawatomi Nation Health Services facilities. I will continue to be
treated based on my eligibility for benefits extended by the CPNHS.
{{intake.FirstName}} {{intake.LastName}}
{{intake.DateBirth | date : 'MM/dd/yyyy'}}
Signature of Patient or Personal Representative/Date
Printed Name of Patient
Patient’s Date of Birth
Print name of signer if different than patient
Relationship to patient
1st Endorsement
Patient declined to sign the Acknowledgement of Privacy Practices Notice Receipt.
CPNHS Employee
Date
