FAMILY PLANNING HEALTH SERVICES, INC. CLIENT #_______________________________________

Name_______________________________________________________________________________________________________________________________________________________

Legal First MI Last Maiden Nickname

Address_______________________________________________________________________________________________________________________County________________________

Street/PO Box City State Zip Code

How can we send mail? ______Family Planning envelope ______Plain envelope ______ Send Elsewhere E-Mail Address_____________________________________

Home Phone_______________________ Work Phone______________________ Cell Phone__________________ Can we call you? At home At work Cell Phone

Can we say we are calling from Family Planning? at home at work cell phone just ask for me answering machine all

Alternate mailing Address (school breaks/summer/other)________________________________________________________From ____/____ to ____/____ Phone_________________________

MM/YY MM/YY

Date of Birth___________________________________ Age______ Social Security #____________________________________________________________________________________

Ethnicity (circle one): Hispanic Non-Hispanic

Race (circle one) Asian African Am Native Am. White

I currently live: alone with partner with spouse with parents with other relative in student dorm with children with friend

The following information is required to be eligible for discounts:

Place of Employment ___________________________ Hours working per week _____________ Hourly wage _____________

If not working, when did you work last? Month_______________ Year___________

If not paid hourly (i.e. self-employed/commission), check here___, and your net income is $__________________ per ____Week ____Month ____Year (check one).

If you live with your spouse/partner, his/her approximate income is $_______________________ per ____Week ____Month ____Year (check one).

Do you receive money from any other source?
Type of Income	Yes/No	If marked ‘yes’, list approximate amount per ____Week ____Month ____Year (check one):
Allowances	 	$
Disability	 	$
Social Security/SSI	 	$
Workers/Unemployment Compensation	 	$
Trust Funds	 	$
Alimony/Child Support	 	$
School Grants/Scholarships	 	$
Parents	 	$
Other income (please describe)	 	$

How many people are supported by this income? ________________

Emergency Contact Person_____________________________________________Relationship_____________________

(must be able to say we are calling from Family Planning)

Address________________________________________________________Phone #_____________________________

Insurance (check all that apply):

______Medical Assistance ______Co-pay/deductible insurance

______FP Waiver (PE Only or Full Coverage) ______Indian health services/Migrant Health

______Other Government (Medicare/Disability) ______No Insurance

______Full pay insurance

If you would like a claim submitted to your insurance company we will need to photocopy your insurance card.

If you are submitting to insurance, you must present your card at the time of visit. If you decline to use your

insurance at the time of visit, FPHS will not submit at a later date and discounts are not available once

you choose to bill Insurance. If you have medical assistance/FP Waiver you are required to present a valid card at each visit.

I hereby certify, under penalty of perjury, that this information is accurate and complete. If my income changes, I agree to notify FPHS at my next visit.

Signature_____________________________________________________________________________________ Date_______________________________________