Lyon Martin Health Services

& Women’s Community Clinic

Patient Intake Information

Name you go by: Date:

For billing purposes, if you have insurance, what gender do they have on record for you? □ Female □ Male

Name as it appears on your insurance card:

Home Address:

City: State: Zip Code:

Mailing Address (if different from Home Address):

City: State: Zip Code:

Home Phone Number: Cell Phone Number:

Can we leave you a confidential message at these phone numbers? □ Yes □ No

E-mail Address:

Date of Birth: Social Security Number:

Emergency Contact: Relationship:

Emergency Contact Phone Number:

If you don’t have contact information, what other social service agencies do you frequent? Please provide a phone

number if possible:

I would prefer to receive my care in: □ English □ Spanish □ Not Listed:

What type of insurance(s)/coverage(s) do you have? We treat everyone regardless of ability to pay.

□ None □ Medi-Cal □ Medicare □ Healthy San Francisco □ CDP/Every Woman Counts

□ Family PACT □ Anthem Blue Cross Medi-Cal □ San Francisco Health Plan □ Not Listed:

We must collect ALL patients’ income information in order to stay in compliance with federal regulation, as Lyon Martin Health Services and

Women’s Community Clinic are Federally Funded Community Health Clinics. (even if you have insurance).

What is your source of income? Please check all that apply.

□ Full 6me employment □ Part-time employment □ Social Security/SSI □ Disability/SSDI

□ General Assistance (GA) □ Unemployment benefits □ Student Loan(s) □ Savings

□ Money from parents □ Money from friends/others □ No income at all □ Not Listed:

What is your household income before taxes? $ each month.

How many dependents are in your household?

Due to federal regulations, we must ask ALL patients their household size and income, regardless of health insurance status. Household members

include those persons living at the same home who are related by birth, marriage, registered domestic partnership, or adoption.

My race/ethnicity is:

□ Na6ve American and/or Alaskan Native

□ Black/African American

□ White/Caucasian

□ Na6ve Hawaiian

□ Asian

□ Other Pacific Islander

□ Not Listed:

□ Decline to specify

I am Hispanic/Latinx: □ Yes □ No □ Declined

I am a seasonal agricultural worker: □ Yes □ No □ Declined

I am a migrant worker: □ Yes □ No □ Declined

I am a veteran: □ Yes □ No □ Declined

My living situation now, or in the last 12 months (please check all that apply):

□ Homeless

□ At risk of being homeless

□ Homeless some6me during the last 12 months

□ Sleeping in the park or on the street

□ Living in a van or car

□ Staying in a shelter

□ Residen6al program or halfway house

□ Living in a hotel/SRO (single room occupancy)

□ Living with friend(s) and/or family (I don’t pay rent)

□ Rent or own room/apartment/house (I pay rent)

□ Not Listed:

Check all that apply:

Gender Identity:

□ Woman

□ Man

□ Trans feminine (MTF)

□ Trans masculine

(FTM)

□ Non-binary

□ Genderqueer

□ Agender

□ Two-spirit

□ Not Listed:

□ Decline

Sex Assigned at Birth:

□ Female

□ Male

□ Intersex

□ Not Listed:

□ Decline

Pronoun(s):

□ She/her/hers

□ He/him/his

□ They/them/theirs

□ Zie/hir/hirs

□ Not Listed:

Sexual Orientation:

□ Lesbian

□ Gay

□ Queer

□ Bisexual

□ Heterosexual

□ Asexual

□ Ques6oning

□ Not Listed:

□ Decline

Marital Status:

□ Single

□ Married

□ Domes6c Partnership

□ Divorced

□ Widowed

□ Unmarried

partnership

□ Legally Separated

□ Not Listed:

□ Decline

I was referred to HealthRight360 by:

□ Case manager/Social worker

□ HealthRight360 outreach worker

□ Community organizer

□ Referred by staff

□ Bus/Radio/Shelter Ad

□ HealthRight360 program

□ Health Plan

□ Not Listed:

□ Family/Friend(s)/Acquaintance(s)

□ Self-referral

□ Internet/Social Media/Yelp

Patient Signature: Date:

Parent/Guardian signature: Date:

A parent or guardian must sign if the patient is under 18 years of age,

UNLESS patient is an emancipated minor OR is being seen for sexual or reproductive health services.

Preferred pharmacy

A simple way to “give back” to Lyon-Martin Health Services (LMHS) and Women’s Community Clinic (WCC) is by

choosing one of these 340B contracted pharmacies.

340 B is a drug pricing program that helps federally qualified health centers (FQHCs) cover the costs of the uninsured

and wrap-around services we provide. The program only applies to our patients when they are prescribed drugs by our

providers.

Walgreens (if you have Medicare or San Francisco Health Plan):

□ 498 Castro St. (Castro Street & 18th Street)

□ 790 Van Ness Ave (Van Ness Avenue & Eddy St)

□ 825 Market St. (Cable Car Turnaround, Union Square)

□ 1189 Potrero Ave (23rd St & 24th St Mission)

□ 1301 Market St. (Fell St & 9th St)

□ 199 Parnassus (Stanyan St & Parnassus St)

□ 1496 Market St. (Van Ness Ave & Fell St)

□ 2145 Market St. (b/t Sanchez St & 15th St)

□ 45 Castro St., Suite 124 (at CPMC-Davies Campus)

□ 2262 Market St. (Sanchez St & 16th St)

□ Mission Wellness Pharmacy 2424 Mission Street (21st St & 20th St Mission)

□ US Bioservices (if you have Medicare or San Francisco Health Plan)

□ Wellpartner or CVS Pharmacies (if you have Medi-Cal Anthem Blue Cross and Medicare)

Please list exact location below:

If these options don’t work for you, please give us your preferred pharmacy’s information below:

Pharmacy Name: __________________________________________________________________________

Location:_________________________________ Phone #:_______________________________________