Confirm Primary Care - Hope Clinic

The Hope Clinic and Care Center Inc. is a free clinic available to anyone who is at 300% of Federal Poverty Level or less. Hope Clinic is considered a safety net facility, which means we provide primary care services to all patients regardless of the person’s ability to pay. Safety net clinics are an important primary care delivery sites for non-Medicaid insured minority and low-income populations with a high burden of chronic illnesses. The critical role of safety net clinics in care delivery is likely to persist despite expanded insurance coverage under the Affordable Care Act. Prior to going to an Emergency Room for a visit, that is non-urgent, please reach out to the Hope Clinic to see if we are able to assist you with your care. We are here to help you Monday – Thursday from 9-5 pm. Our mission is to help care for you in body, mind and spirit. *

Patient Name

I have read and understand that the Hope Clinic and Care Center Inc. is a safety net provider and is my Primary Care Clinic. I agree that they provide my primary care and additional services as a patient at the Clinic:

If patient is a Minor, Enter Parent/Guardian Name Above:

I acknowledge as the patient or parent/guardian that I have read and understand the above statement. *

By signing this form, I recognize that as a patient of the Hope Clinic & Care Center Inc. there is no medical care available from the Hope Clinic & Care Center Inc. Staff contact an urgent care center for problems that cannot wait until my next scheduled appointment. I further agree that I will not contact any Hope Clinic & Care Center Inc. providers at their individual medical business facilities for any reasons related to my exam at the Hope Clinic & Care Center Inc. *

Signature of Acknowledgment of Primary Care by Patient or if minor by Parent or Guardian: *

Clear

Date Signed: *

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