Step 1 of 2 50% Community Bridge Clinic Enrollment – AdultPatient InformationFull Legal Name of Person Receiving Services(Required) First Last Date of Birth(Required) MM slash DD slash YYYY AgeAddress(Required) Street Address Address Line 2 City 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 State ZIP Code Sex(Required) Female Male Other Ethnicity(Required) Hispanic Non-Hispanic Race(Required) Unknown American Indian Pacific Island Alaskan Native Black Asian White Other Primary Language(Required) I agree voicemail messages can be left for me on:(Required) Home phone Cell phone Work phone Home phoneCell phoneWork phoneMy Email address is Primary Care Provider Name Primary Care Provider PhoneDentist's Name Dentist PhoneHave you seen this dentist/group in the last year? Yes No Any dental issues? Insurance InformationDo you have insurance (private/Medicaid/Husky)?(Required) Yes No Medical Insurance Private Insurance ID/Policy # Medicaid ID# Insurance Address Street Address Address Line 2 City 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 State ZIP Code Insurance Phone # (on back of card)Policy Holder Name(Required) First Last Policy Holder Date of Birth(Required) MM slash DD slash YYYY Is there additional insurance?(Required) Yes No Private Insurance ID/Policy # Group Number Insurance address(Required) Street Address Address Line 2 City 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 State ZIP Code Insurance Phone # (on back of card)Policy Holder Name(Required) First Last Policy Holder Date of Birth(Required) MM slash DD slash YYYY Emergency ContactsEmergency Contact 1 – Name First Last Emergency Contact 1 – Relationship to Patient Emergency Contact 1 – PhoneEmergency Contact 2 – Name First Last Emergency Contact 2 – Relationship to patient Emergency Contact 2 – PhoneOther contactsPlease list others with whom we may discuss your medical care, including family members and other providers.Contact 1 – Name Contact 1 – Relationship Contact 2 – Name Contact 2 – Relationship Contact 3 – Name Contact 3 – Relationship Medical HistoryDate of last physical exam? MM slash DD slash YYYY Do you have any medical conditions?(Required) Yes No Explain(Required)Do you take any medications (including inhalers or vitamins)?(Required) Yes No List:(Required)Have you had any serious injuries (including a head injury)?(Required) Yes No Explain(Required)Do you have a birth or heart defect?(Required) Yes No Explain(Required)Have you ever been hospitalized overnight?(Required) Yes No Explain(Required)Have you had any surgeries in the past?(Required) Yes No Explain(Required)Do you have any problems with sleeping and/or snoring?(Required) Yes No Explain(Required)Have you had a dental cleaning within the past 6-12 months?(Required) Yes No Approximate date of last cleaning(Required) MM slash DD slash YYYY Does anyone smoke in the home?(Required) Yes No Do you smoke, use e- cigarettes, or chew tobacco?(Required) Yes No Do you get 60 min of exercise at least 3 times a week?(Required) Yes No Are you concerned with the amount of time you spend on social media, T.V., video games, computer, or phone?(Required) Yes No Explain(Required)Do you have concerns about your health or weight?(Required) Yes No Explain(Required)Patient History of the Following:Anemia/Blood disorders(Required) Yes No Asthma(Required) Yes No Alcohol/substance abuse(Required) Yes No Cancer/Leukemia(Required) Yes No COVID 19(Required) Yes No Diabetes/ Endocrine/ Gland Disease /Autoimmune(Required) Yes No Digestive issues/Diarrhea/Constipation(Required) Yes No Headaches/Migraines(Required) Yes No Gynecologic issues (for women) Yes No Seasonal Allergies(Required) Yes No Heart murmur(Required) Yes No Skin problems (eczema, acne, etc.)(Required) Yes No Seizures(Required) Yes No Overweight or Obesity(Required) Yes No Other Patient History:Family History – Please Note Relationship to PatientAnemia/blood disorders(Required) Yes No Relationship to Patient(Required) ADD/ADHD(Required) Yes No Relationship to Patient(Required) Asthma(Required) Yes No Relationship to Patient(Required) Cancer/Leukemia(Required) Yes No Relationship to Patient(Required) Diabetes/ Endocrine/ Gland Disease /Autoimmune(Required) Yes No Relationship to Patient(Required) Headaches/ Migraines(Required) Yes No Relationship to Patient(Required) Overweight/ Obesity(Required) Yes No Relationship to Patient(Required) Skin problem (acne, eczema, etc.)(Required) Yes No Relationship to Patient(Required) Mental Health Issues(Required) Yes No Relationship to Patient(Required) Seizures(Required) Yes No Relationship to Patient(Required) Heart Disease(Required) Yes No Relationship to Patient(Required) Hypertension(Required) Yes No Relationship to Patient(Required) Substance Use(Required) Yes No Relationship to Patient(Required) Tobacco Use(Required) Yes No Relationship to Patient(Required) Other Family History:AllergiesAny foods (including lactose intolerance)?(Required) Yes No Explain(Required)Any medications? (including over the counter or antibiotics)(Required) Yes No Explain(Required)Do you have an Epi-Pen (or similar prescription) for use in case of anaphylaxis?(Required) Yes No Explain(Required)Other Allergies:Behavioral HealthHave you ever received counseling services(Required) Yes No When and with whom?(Required) Are you interested in receiving information about mental health counseling?(Required) Yes No Have you recently had any of the following:Family changes(Required) Yes No Work issues(Required) Yes No Social/peer stresses(Required) Yes No Anxiety/Panic Attacks(Required) Yes No Anger issues(Required) Yes No ADHD/Attention issues(Required) Yes No Depression(Required) Yes No Recent loss/crisis(Required) Yes No By signing below, I understand and acknowledge I have read and understand this consent:(Required) I give permission for myself to obtain routine health services at the Community Bridge Clinic. All insurances will be billed at the time of visit. Sliding scale for payment available for those without medical insurance RELEASE OF INFORMATION AND PAYMENT AUTHORIZATION(Required) I authorize the release of any medical or behavioral health information necessary to process my claim. I also authorize payment of health benefits to Child & Family Agency for services provided. CONSENT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES(Required) I understand and acknowledge that I have read and understand this consent and I have received CFA’s Notice of Privacy Practices currently in effect. I understand that information regarding how CFA will use and disclose my information can be found in CFA’s Notice of Privacy Practices. I understand my consent is effective for as long as CFA maintains my protected health information. AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMATION I give permission to allow Child & Family Agency (CFA) to exchange as needed information with my primary medical provider in order to effectively care. I also certify that the health information provided is accurate to the best of my knowledge and understand that incorrect information can be dangerous to my health. I will notify the Community Bridge Clinic of any changes to medical information. By signing below, I understand that this authorization is valid until I revoke this authorization. I understand I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent. Signature of Patient/Personal Representative:(Required) Signature Date(Required) MM slash DD slash YYYY Authorization for Health Information Exchange (HIE)The HIE system is a secure computer system that brings your protected health information from different healthcare locations into one nationwide electronic health record. The HIE system network provides participating practitioners access to past and present medical and behavioral health information to make better decisions and better coordinate care across your care teams. The HIE system takes your privacy and security very seriously. The HIE system does not store any of your health/clinical data and uses end-to-end encryption to help ensure your data is secure when sending data. Only those involved in your care can look at your information.Patient's Name(Required) First Last Patient Date of Birth(Required) MM slash DD slash YYYY The State of Connecticut participates in the Health Information Exchange, meaning that medical health information (e.g. immunizations, medications, physical examinations, etc.) are shared with other medical providers unless a specific opt-out is received.Do you want to opt-out of any medical information being sent to other health care providers?(Required) Yes No Additionally, sensitive PHI is PHI that is “subject to heightened confidentiality requirements in compliance with all federal and state laws as amended from time-to-time (e.g. HIV, substance abuse and mental health records).”Patients must specifically authorize disclosures of sensitive PHI.Do you want to opt-out of sensitive PHI (e.g. HIV, substance abuse, and mental health records) being sent to other providers?(Required) Yes No By signing below, I understand and acknowledge the following: My sensitive health information will be available to providers using The HIE system. I understand that refusal to sign this authorization form will not affect my right to obtain present and future services. I also understand that I may opt-out of HIE by notifying Child and Family Agency of the named recipient in writing. Electronic signature of person authorizing health information exchange Today's Date(Required) MM slash DD slash YYYY
