Application For renewing patients only Returning Patient Application HIPAA-compliant form for returning medical and/or dental patients. VerificationAge Verification(Required) I am between 18-64 yrs oldWork Verification(Required) I'm working, I'm a caregiver, I'm a volunteer, or I attend schoolPersonal InfoName(Required) First Middle Last Today's Date(Required) Birthdate(Required) Marital Status(Required) Married Divorced Widowed Single Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Sex(Required) Male Female My status is:(Required) First Time Applicant Renewing Patient I'm applying for:(Required) Medical Services Only Dental Services Only Both Medical and Dental Services Ethnicity(Required) Hispanic or Latino Neither Hispanic no Latino Race(Required) Asian Black Middle Eastern or North African White Other Preferred Language(Required) English Spanish Other Daytime Phone(Required)Cell PhoneDo you receive text messages?(Required)If you answered Yes, you will receiove a text message from us when your application has been processed. Yes No Email(Required) Enter Email Confirm Email Employment and IncomeSelect all that apply(Required) I have a source of income I'm a student I'm a volunteer What is your source of income?(Required)(e.g., place of employment, babysitting, house cleaning, DoorDash)Which school do you attend?(Required)Where do you volunteer?(Required)Total income your entire household earns each month:(Required)This is total income before taxes.How many people are currently in your household?(Required)This number must reflect the number of dependents you claim on your tax return. Please enter a number from 1 to 10.Emergency ContactEmergency Contact Person(Required)Emergency Contact Phone(Required)Emergency Contact Relationship to Applicant(Required) Spouse Parent Child Other Do you receive any of the following?(Required)Check all that apply. Medicaid Medicare Veteran's Benefits Medical and/or Health Insurance Dental Insurance Receive or Applied for Social Security Disability None of the above List your insurance company(Required)Would you like a Patient Portal account?Bethesda Medical patients have the option to have a Patient Portal account. With the Patient Portal you can request medical appointments, upload income information, send & receive messages, view lab results, and more. Yes No Dental Applicants OnlyDental services NOT provided: implants, complete dentures, orthodontic treatment, periodontal surgery, sedation or nitrous oxide, and select impacted dental extractions. I Understand: The first dental visit cost $70. $50 is required as a deposit to schedule this appointment and the remaining $20 is due on the appointment date. A refund cannot be given if you miss your first appointment. Fees for all dental services are separate from the first visit fee. Dental prices will vary based on the services needed and a deposit (at least 50% of the treatment scheduled or $50 for hygiene) is required at the time of scheduling an appointment. All deposits for dental care must be used within 12 months. Unused deposits will be refunded (minus any missed appointment fees). Refunds will be processed by credit card or check. Unclaimed refunds may be sent to the State of Texas as required by law. For cancellations and rescheduling, you must provide at least 24 hours’ advance notice. If you cancel an appointment for the same day or fail to appear, you will lose up to $60 of your deposit. Arriving 10 minutes or more late to your appointment may mean you are not seen and may lose your deposit. After (2) missed “no-show” appointments in 12 months, you may no longer be eligible for care.Dental Conditions and Guidlines Dental Applicants Only By checking the box I confirm that I have read and agree to the Conditions and Guidelines above. Information for Children ApplyingAre you also applying for a child(ren)(Required)NoYesHow many children?(Required)Choose one1234567Child's Name(Required) First Last Child's Gender(Required)Choose oneMaleFemaleChild's Date of Birth(Required) My Child has...(Required)Choose oneMedicaidCHIPSNeitherSecond Child's Name(Required) First Last Second Child's Gender(Required)Choose oneMaleFemaleSecond Child's Date of Birth(Required) My Second Child has...(Required)Choose oneMedicaidCHIPSNeitherThird Child's Name(Required) First Last Third Child's Gender(Required)Choose oneMaleFemaleThird Child's Date of Birth(Required) My Third Child has...(Required)Choose oneMedicaidCHIPSNeitherFourth Child's Name(Required) First Last Fourth Child's Gender(Required)Choose oneMaleFemaleFourth Child's Date of Birth(Required) My Fourth Child has...(Required)Choose oneMedicaidCHIPSNeitherFifth Child's Name(Required) First Last Fifth Child's Gender(Required)Choose oneMaleFemaleFifth Child's Date of Birth(Required) My Fifth Child has...(Required)Choose oneMedicaidCHIPSNeitherSixth Child's Name(Required) First Last Sixth Child's Gender(Required)Choose oneMaleFemaleSixth Child's Date of Birth(Required) My Sixth Child has...(Required)Choose oneMedicaidCHIPSNeitherSeventh Child's Name(Required) First Last Seventh Child's Gender(Required)Choose oneMaleFemaleSeventh Child's Date of Birth(Required) My Seventh Child has...(Required)Choose oneMedicaidCHIPSNeitherAll ApplicantsI Understand: I am required to pay my office visit co-pay, dental initial visit fee, and/or any other office visit fees each time I have an appointment at Bethesda. If I cannot pay, I may not receive care and may be referred to a patient advocate to be matched up with other resources. All co-pays and fees must be paid in cash or by credit card. Fees for all dental services, labs, x-rays, women’s health, and specialty services are separate. They may be in addition to my medical office visit co-pay, dental initial visit fee, and will vary depending on the test or procedure. If I miss a scheduled appointment and fail to provide at least 24 hours advance notice it could impact my eligibility as a Bethesda patient. Failure to appear at my initial visit or the cancellation of any three appointments can result in my dismissal as a patient. If I cancel an appointment on the same day as that appointment or if I miss an appointment and do not call ahead, I will forfeit any prepaid fees for that appointment. If I am over 10 minutes late, to any appointment, I will not be seen. Specialty services and referrals at Bethesda are limited. They are prioritized for patients where Bethesda is their primary healthcare provider. Not all patients will have access to specialty services and/or referrals. I understand it is my responsibility to keep my contact information current to receive any refund. I understand and agree to the conditions and guidelines stated above.Conditions and Guidlines ConfirmationAll Applicants By checking the box I confirm that I have read and agree to the Conditions and Guidelines above. Required Documents ConfirmationAll Applicants By checking the box I confirm that I must bring proof of income (check stub), a valid photo ID and latest tax return (1040 pages 1 & 2) to my first appointment, unless I have made other arrangements with the Bethesda Health Clinic Admissions Department. Waiver of Liability for TreatmentThe Medical/Dental treatment provided by Bethesda Health Clinic, a charitable non-profit organization (the “Clinic”), is provided by volunteer healthcare providers who do not receive compensation. Texas Law (Texas Charitable Immunity and Liability Act of 1987 [as amended]), as well as Federal Law (Volunteer Protection Act of 1997), provides IMMUNITY FROM CIVIL LIABILITY for any act or omission resulting in death, damage, or injury if the volunteer was acting in good faith and in the course of his/her duties or functions within the organization. By signing below, you acknowledge: (1) that the Clinic’s volunteer healthcare providers (such as physicians, physician assistants, registered nurses, licensed vocational nurses, pharmacists, podiatrists, dentists, dental hygienists, optometrists, or any such persons who are retired or otherwise defined or included under Texas law or Federal law) are providing health care that is not administered for or in expectation of compensation; and (2) that there are limitations on you or your family’s ability to recover damages from the volunteer or the Bethesda Health Clinic in exchange for your receiving health care services. It is intended that this WAIVER be as broad and expansive as allowed by law.Submit ApplicationBy clicking the Submit button below, I hereby declare that the above information is true and correct and that I have read and agree to the Waiver of Liability for Treatment. I know that any false information could jeopardize my eligibility to receive medical and/or dental attention at Bethesda Health Clinic.
