Pre-Registration for Swope Health KidsCARE Behavioral Health

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Sliding Fee Discount Eligibility: It may be necessary for Swope Health to ask personal questions in order to determine eligibility for a discount on medical, dental or qualified behavioral health services. This information is private and confidential and is kept on file at Swope Health. Income verification is determined once a year and requires proof of income and proof of address documents to be returned to Swope Health. (Family size and annual gross household income are used to calculate discount and level of payment.)

GENERAL CONSENT FOR DIAGNOSIS AND TREATMENT AND TELEHEALTH

I, having registered at Swope Health for the purposes of obtaining health services, do hereby, voluntarily consent to diagnostic and treatment services for ______________________________ (Patient Name), as might be provided by or at the direction of a physician, dentist, other health care professional or other qualified member of the staff of the Swope Health to me according to his/her judgment. By signing below, I also consent to treatment by students in residency and/or affiliation programs with Swope Health.

This form has been fully explained to me, and I certify that I understand its contents.