JFCS Intake Portal

All information is strictly confidential.

Please read thoroughly and fill out the form completely as it pertains to yourself, or the person you are helping.

Each section of the form is validated before you can progress to the next.

Basic Information

Required
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Please provide a valid email address.
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Please enter a valid phone number in the format of 123-456-7890
Please enter a valid phone number in the format of 123-456-7890
Please enter a valid date in the format of mm/dd/yyyy. For example, 05/21/1972
Please select one.

Demographics


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Referrals


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Education

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Employment

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Household


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Instructions: Click on the button above to to add a household member. Click on the next to a name to remove a member.

All fields for each member are required

Gender
DOB
Relationship
Gender
DOB
Relationship
Gender
DOB
Relationship
Gender
DOB
Relationship

Parent/Guardian/Caregiver

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Emergency Contact

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Medical Insurance


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Notice of Privacy Practices

I understand that Jewish Family & Child Service will use and disclose health information about me.  I understand that my health information may include information both created and received by the practice/facility, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.

I understand and agree that Jewish Family & Child Service may use and disclose my health information in order to:

  • Make decisions about and plan for my care and treatment:
  • Refer to, consult with, coordinate among, and manage along with other health care providers and agency staff for my care and treatment;
  • Determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and
  • Perform various office, administrative and business functions that support my practitioner/provider's efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care.

I also understand that I have the right to receive and review a written description of how Jewish Family & Child Service will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of Jewish Family & Child Service, and my rights regarding my health information.

I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of Jewish Family & Child Service’s Notice of Privacy Practices in effect will be posted in waiting/reception area.

I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that Jewish Family & Child Service is not required by law to agree to such requests.

I understand that it is Jewish Family & Child Service Policy to obtain my signature on a Release of Information whenever possible.

You must agree to this.
You must type your name in.
Please enter your relationship to patient. If you are the patient, type self.

Authorization to Use/Disclose Health and Case Management Information

I authorize Jewish Family & Child Service to use and disclose Health and /or Case Management information, and a copy of the specific health and clinical information described below regarding:

Consisting of: Assessment and case notes referring to billing

Your initials are required.
Medical Treatment; Alcohol / Drug Treatment; Psychiatric Treatment; HIV Tests, Diagnosis, Treatment; Mental Health Treatment; Financial Information; Disability Information
Unless otherwise specified, Medical Treatment, Psychiatric Treatment, Mental Health Treatment, and Alcohol / Drug Treatment may include all aspects of diagnosis, treatment and prognosis.

To: INSURANCE PROVIDER

For the Purpose of: BILLING

Your health care and payment for that health care cannot be conditioned upon receipt of this signed Authorization unless your health care or treatment is for the purpose of:

(1) Creating health information about you to be disclosed to a third party; or

(2) For the purpose of research.

You have the right to revoke this Authorization at any time, provided that you do so in writing. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

To revoke this Authorization, please send a written statement to:

JFCS Program Manager
1221 SW Yamhill St, Suite 301
Portland, OR 97205

Your statement must identify the date you signed this Authorization, the recipient of the information identified in this Authorization, and state that you are revoking this Authorization. This Authorization will expire 180 days from the date of signing, or the end of the period reasonably needed to complete the disclosure for the above-described purpose, whichever comes firs.

You must agree to this.
You must type your name in.
Please enter your relationship to patient. If you are the patient, type self.