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Child and Family Agency

Child and Family Agency

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Forms – CBC Child Enrollment


Step 1 of 3

33%

Community Bridge Clinic Enrollment - Child

Patient Information

Full Legal Name of Person Receiving Services(Required)
MM slash DD slash YYYY
Address(Required)
Assigned Sex(Required)

Ethnicity(Required)
Race(Required)

Does the patient attend school?(Required)

Insurance Information

Do you have insurance (private/Medicaid/Husky)?(Required)
Insurance Address
Policy Holder Name(Required)
MM slash DD slash YYYY
Is there additional insurance?(Required)
Insurance address(Required)
Policy Holder Name(Required)
MM slash DD slash YYYY

Parent/Guardian Information

Parent/Guardian Name(Required)
MM slash DD slash YYYY
Address (if different from patient)
I agree voicemail messages can be left for me on:(Required)
Do You Have a Primary Care Provider?(Required)
Has your child seen this dentist/group for 1+ year(s)

Second Emergency Contact

Name

Medical History

MM slash DD slash YYYY
Does the patient have any medical conditions?(Required)
Does the patient take any medications (including inhalers or vitamins)?(Required)
Has the patient had any serious injuries (including a head injury)?(Required)
Does the patient have a birth or heart defect?(Required)
Has the patient ever been hospitalized overnight?(Required)
Has the patient had any surgery in the past?(Required)
Does the patient have any problems with sleeping and/or snoring?(Required)
Has the patient had a dental cleaning within the past 6-12 months?(Required)
MM slash DD slash YYYY
Does anyone smoke in the home?(Required)
Does the patient smoke, use e- cigarettes, or chew tobacco?(Required)
Does the patient get 60 min of exercise at least 3 times a week?(Required)
Are you concerned with the amount of time your child spends on social media, T.V., video games, computer, or phone?(Required)
Any other concerns about your child’s health or weight?(Required)

Patient History of the Following:

Anemia/Blood disorders(Required)
Asthma(Required)
Autism(Required)
COVID 19(Required)
Cancer/Leukemia(Required)
Diabetes/ Endocrine/ Gland Disease /Autoimmune(Required)
Digestive issues/Diarrhea/Constipation(Required)
Headaches/Migraines(Required)
Learning/Developmental Issues(Required)
Seasonal Allergies(Required)
Heart murmur(Required)
Skin problems (eczema, acne, etc.)(Required)
Seizures(Required)
Overweight or Obesity(Required)

Family History - Please Note Relationship to Patient

Anemia/blood disorders(Required)
ADD/ADHD(Required)
Asthma(Required)
Cancer/Leukemia(Required)
Diabetes/ Endocrine/ Gland Disease /Autoimmune(Required)
Headaches/ Migraines(Required)
Overweight/ Obesity(Required)
Skin problem (acne, eczema, etc.)(Required)
Mental Health Issues(Required)
Seizures(Required)
Heart Disease(Required)
Hypertension(Required)
Substance Use(Required)
Tobacco Use(Required)

Allergies

Any foods (including lactose intolerance)?(Required)
Any medications? (including over the counter or antibiotics)(Required)
Does the patient have an Epi-Pen (or similar prescription) at home/school?(Required)

Behavioral Health

Has the patient ever had or is currently receiving counseling services(Required)
With CFA?(Required)
Are you interested in receiving information about mental health counseling for your child?(Required)
Has the patient ever had any of the following:
Family changes(Required)
School issues(Required)
Social/peer stresses(Required)
Anxiety/Panic Attacks(Required)
Learning Disabilities(Required)
Anger issues(Required)
ADHD/Attention issues(Required)
Depression(Required)
Truancy/School avoidance
Recent loss/crisis(Required)
By signing below, I understand and acknowledge I have read and understand this consent:(Required)
RELEASE OF INFORMATION AND PAYMENT AUTHORIZATION(Required)
CONSENT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES(Required)
AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMATION
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.
MM slash DD slash YYYY

School-Based Health Center Clients

By 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.

All 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
AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMTION(Required)
I understand that SBHC medical and mental health providers may communicate with each other about my child's care if indicated.
MM slash DD slash YYYY
Client or authorized person's 18 years of age or older name(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)
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)
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)

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.

MM slash DD slash YYYY
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