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 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 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 attendsSelect 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 are part of the best practice guidelines for medical care. Parents/guardians will be notified before screening visit. Annual Risk Assessment Screening Visits Check box to opt OUT AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMTION 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 MM slash DD slash YYYY
