Step 1 of 2 50% Community Bridge Clinic Enrollment Form (for vaccines only)Patient 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 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) Primary Care Provider Name Primary Care Provider PhoneInsurance 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 Information (if patient is a minor)Parent/Guardian Name First Last Relationship to Patient Date of Birth 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: Home phone Cell phone Work phone Home phoneCell phoneWork phoneParent/Guardian Email Acknowledgement and SignatureBy signing below, I understand and acknowledge I have read and understand this consent:(Required) I give permission for myself or my child to obtain vaccination 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. There is never any out of pocket charge for COVID-19 vaccines. RELEASE OF INFORMATION AND PAYMENT AUTHORIZATION(Required) I authorize the release of any medical 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. I 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, 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 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
