Step 1 of 3 33% Community Bridge Clinic Enrollment – ChildPatient InformationFull Legal Name of Person Receiving Services(Required) First Last Date of Birth(Required) MM slash DD slash YYYY 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 Assigned Sex(Required) Female Male Other Ethnicity(Required) Hispanic Non-Hispanic Race(Required) Unknown American Indian Pacific Island Alaskan Native Black Asian White Other Patient's Primary Language(Required) Does the patient attend school?(Required) Yes No School child attends(Required) Grade(Required) 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 Parent/Guardian InformationParent/Guardian Name(Required) First Last Relationship to Patient(Required) Date of Birth(Required) MM slash DD slash YYYY Address (if different from patient) 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 I agree voicemail messages can be left for me on:(Required) Home phone Cell phone Work phone Home phoneCell phoneWork phoneParent/Guardian Email Child's Email (if relevant) Child's Cell Phone # (if relevant)Do You Have a Primary Care Provider?(Required) Yes No Child's Primary Care Provider Name Primary Care Provider PhoneChild's Dentist Name Dentist PhoneHas your child seen this dentist/group for 1+ year(s) Yes No Second Emergency ContactName First Last Relationship to Student PhoneMedical HistoryDate of last physical exam? MM slash DD slash YYYY Does the patient have any medical conditions?(Required) Yes No Explain(Required)Does the patient take any medications (including inhalers or vitamins)?(Required) Yes No Explain(Required)Has the patient had any serious injuries (including a head injury)?(Required) Yes No Explain(Required)Does the patient have a birth or heart defect?(Required) Yes No Explain(Required)Has the patient ever been hospitalized overnight?(Required) Yes No Explain(Required)Has the patient had any surgery in the past?(Required) Yes No Explain(Required)Does the patient have any problems with sleeping and/or snoring?(Required) Yes No Explain(Required)Has the patient 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 Does the patient smoke, use e- cigarettes, or chew tobacco?(Required) Yes No Does the patient get 60 min of exercise at least 3 times a week?(Required) Yes No Are you concerned with the amount of time your child spends on social media, T.V., video games, computer, or phone?(Required) Yes No Explain(Required)Any other concerns about your child’s health or weight?(Required) Yes No Explain(Required)Patient History of the Following:Anemia/Blood disorders(Required) Yes No Asthma(Required) Yes No Autism(Required) Yes No COVID 19(Required) Yes No Cancer/Leukemia(Required) Yes No Diabetes/ Endocrine/ Gland Disease /Autoimmune(Required) Yes No Digestive issues/Diarrhea/Constipation(Required) Yes No Headaches/Migraines(Required) Yes No Learning/Developmental Issues(Required) 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)Does the patient have an Epi-Pen (or similar prescription) at home/school?(Required) Yes No Explain(Required)Other Allergies:Behavioral HealthHas the patient ever had or is currently receiving counseling services(Required) Yes No With CFA?(Required) Yes Other When and with whom?(Required) Are you interested in receiving information about mental health counseling for your child?(Required) Yes No Has the patient ever had any of the following:Family changes(Required) Yes No School issues(Required) Yes No Social/peer stresses(Required) Yes No Anxiety/Panic Attacks(Required) Yes No Learning Disabilities(Required) Yes No Anger issues(Required) Yes No ADHD/Attention issues(Required) Yes No Depression(Required) Yes No Truancy/School avoidance 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 my child 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 child’s medical provider in order to effectively care for my child. I understand that CFA medical and mental health providers may communicate with each other about my child’s care if indicated. 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 the patient’s 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 Parent/Legal Guardian/Personal Representative (or Student if over 18 years old):(Required) Signature Date(Required) MM slash DD slash YYYY School-Based Health Center ClientsBy signing below, I understand and acknowledge I have read and understand this consent: I give permission for my child/self to obtain routine health services at the School-Based Health Center.My child attends(Required)Select schoolBennie Dover Jackson Middle SchoolCatherine Kolnaski Magnet SchoolGrasso TechGroton Middle SchoolFitch Senior High SchoolHarbor Elementary SchoolJennings Elementary SchoolMystic River Magnet SchoolNathan Hale Elementary SchoolNew London High SchoolNortheast AcademyRegional Multicultural Magnet SchoolStonington Middle SchoolThames River Magnet SchoolThe Friendship SchoolWinthrop Elementary SchoolMy child does not attend one of these schoolsAll insurances will be billed at time of visit. No out-of-pocket costs for medical services rendered in school. No one will be refused services due to the inability to pay. Annual Risk Assessment Screening visits may be completed for healthy lifestyle assessment and part of the best practice guidelines for medical care. Parents/guardians will be notified before screening visit. Annual Assessment Screening Visits Check box to opt OUT AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMTION(Required) I give permission to allow Child & Family Agency (CFA) to exchange as needed information with my child’s medical provider, school nurse, and key school personnel in order to effectively care for my child. I understand that SBHC medical and mental health providers may communicate with each other about my child’s care if indicated.Client or authorized person's 18 years of age or older signature for exchange of Health and Education Information(Required) Date of authorization for exchange of Health and Education Information(Required) MM slash DD slash YYYY Client or authorized person's 18 years of age or older name(Required) First Last Client or authorized person's 18 years of age or older signature(Required) Date of signature(Required) MM slash DD slash YYYY By signing above, 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. I understand that my child will continue to be enrolled in a CFA SBHC as long as child is enrolled in school that has a CFA SBHC, although yearly updated will be requested. I recognize that health records, if received by the school district, may not be protected by the HIPAA Privacy Rule, but will become education records protected by the Family Education Right and Privacy Act. 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's 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(Required) Relationship to Patient (If <18 years of age): Today's Date MM slash DD slash YYYY
