SBHC Registration (rev 20200720) Registration form for new patients at our School Based Health Centers. Rev 2020-07-20 Step 1 of 9 11% STUDENT INFORMATIONFull legal name (of person who will receive services)* First Last Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender* Male Female Ethnicity* Hispanic Non-Hispanic Primary language* Race* Unknown American Indian Pacific Islander Alaskan Native Black Asian White Other Does the student qualify for free/reduced lunch?* Yes No School Student Attends* Grade* Primary Medical Care Provider Name* Primary Care Phone NumberStudent's Dentist's Name* Student's Dentist's Phone*Has your child seen this dentist/group for 1+ years?* Yes No INSURANCE INFORMATIONCoverage* Husky / Medicaid Commercial / Private Insurance No Insurance Primary Medical Insurance* Member ID #* SS# can be used if Husky ID is unknownGroup Number Insurance Phone #*On back of cardPolicy Holder Date of Birth* MM slash DD slash YYYY Secondary Insurance Member ID #* SS# can be used for Husky if ID unknownGroup Number Insurance Phone # On back of cardPolicy Holder Name First Last Policy Holder Date of Birth MM slash DD slash YYYY Secondary Insurance Member ID # Group Number Insurance Phone #On back of cardPolicy Holder Name First Last Policy Holder Date of Birth MM slash DD slash YYYY PARENT/GUARDIAN INFORMATIONName* First Last Relationship to Student* Date of Birth MM slash DD slash YYYY Address If different from above Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I agree that voicemail messages can be left for me on (check all that apply) Home phone Cell phone Work phone Home PhoneCell PhoneWork PhoneParent/Guardian Email Address* Enter Email Confirm Email Student Cell PhoneStudent Email Address EMERGENCY CONTACTEmergency Contact (1) Name First Last Relationship (1) to Student Emergency Contact (1) Phone NumberEmergency Contact (2) Name First Last Relationship (2) to Student Emergency Contact (2) Phone MEDICAL HISTORYDate of Last Physical Exam MM slash DD slash YYYY Does the patient have any medical conditions? Yes No If yes, explain: Does the patient take any medications (including inhalers or vitamins)? Yes No If yes, list the medications Has the patient had any serious injuries (including a head injury)? Yes No If yes, explain: Does the patient have a birth or heart defect? Yes No If yes, explain: Has the patient ever been hospitalized overnight? Yes No If yes, explain: Has the patient had any surgery in the past? Yes No If yes, explain: Does the patient have any problems with sleeping and/or snoring? Yes No If yes, explain: Has the patient had a dental cleaning within the past 6-12 months? Yes No Approximate date of last dental cleaning MM slash DD slash YYYY Does anyone smoke in the home? Yes No Does the patient smoke, use e- cigarettes, or chew tobacco? Yes No Does the patient get 60 min of exercise at least 3 times a week? Yes No Are you concerned with the amount of time your child spends on social media, T.V., video games, computer, or phone? Yes No If yes, explain your concerns about social media or screen time Any other concerns about your child’s health or weight? Yes No If yes, explain: PAST AND PRESENT PROBLEMSPATIENT HISTORY of any of the following: Anemia/Blood Disorders Asthma Autism Birth defects (Heart, Lung, Brain, etc.) Cancer/Leukemia Diabetes / Endocrine / Gland Disease / Autoimmune Digestive Issues / Diarrhea / Constipation Headaches / Migraines Learning/Developmental Issues Seasonal Allergies Heart Murmur Skin Problem (Eczema, Acne, etc.) Seizures Overweight or Obesity Other List any other problems FAMILY HISTORY of any of the following:Anemia/blood disorders Yes No If yes, explain relationship to patient ADD/ADHD Yes No If yes, explain relationship to patient Asthma Yes No If yes, explain relationship to patient Cancer/leukemia Yes No If yes, explain relationship to patient Diabetes/Endocrine/Gland disease/Autoimmune Yes No If yes, explain relationship to patient Headaches/Migraines Yes No If yes, explain relationship to patient Overweight/Obesity Yes No If yes, explain relationship to patient Skin problem (acne, eczema, etc.) Yes No If yes, explain relationship to patient Mental health issues Yes No If yes, explain relationship to patient Seizures Yes No If yes, please explain relationship to patient Heart disease Yes No If yes, explain relationship to patient Hypertension Yes No If yes, explain relationship to patient Substance use Yes No If yes, explain relationship to patient Tobacco use Yes No If yes, please explain List any other problems and relationships to patient ALLERGIESAny foods? (including lactose intolerance) Yes No If yes, explain: Any medications? (including over the counter or antibiotics) Yes No If yes, explain: Does the patient have an Epi-Pen (or similar prescription) at school? Yes No If yes, explain: Explain any other allergies BEHAVIORAL HEALTHHas the patient ever had or currently receiving counseling services? Yes No If yes, when and with whom were the counseling services? Are you interested in receiving information about mental health counseling at the SBHC?* Yes No Has the patient ever had any of the following: Significant family changes School issues Social/peer stress Anxiety Learning disabilities Anger issues Attention difficulties Sadness and/or mood swings Truancy/school avoidance Recent loss/crisis If answered yes to any of the above, please comment: ACKNOWLEDGEMENT AND CONSENTBy 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. Well-child screening visits may be completed for healthy lifestyle assessment, for students with asthma, and for students who receive behavioral health services. RELEASE OF INFORMATION AND PAYMENT AUTHORIZATION 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 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, school nurse, and key school personnel in order to effectively care for my child. 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 School-Based Health Center of any changes to medical information. Signature of Parent/Legal Guardian/Personal Representative (or Student if over 18 years old):* Date* 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 updates 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 Rights and Privacy Act.
