SBHC Registration (rev 20220930) Registration form for new patients at our School Based Health Centers. Rev 2022-09-30 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 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* Male Female Other Other: optional Ethnicity* Hispanic Non-Hispanic Language Spoken at home:* 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* INSURANCE INFORMATIONCoverage* Husky/Medicaid Commercial/Private Insurance No Insurance Medicaid ID #* Policy Holder Name* First Last Policy Holder Date of Birth* MM slash DD slash YYYY Primary Medical Insurance* Member ID #* SS# can be used if Husky ID is unknownGroup Number 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 cardIs there secondary insurance?* Yes No Secondary Policy Holder Name* First Last Secondary Policy Holder Date of Birth* MM slash DD slash YYYY Secondary Insurance* Secondary Member ID #SS# can be used for Husky if ID unknown Secondary Group Number 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 Secondary Insurance Phone # On back of card 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 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 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's Cell PhoneStudent's Email Address Student's Primary Care Provider's Name (if none please write “none”):* Student's Dentist's Name (if none please write “none”):* SECOND EMERGENCY CONTACTName First Last Relationship to Student Phone Number 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 ever been hospitalized overnight?* Yes No If yes, explain:* Has the patient had any surgery in the past?* 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 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 none List any other problems FAMILY HISTORY of any of the following:Anemia/blood disorders* Yes No ADD/ADHD* Yes No Asthma* Yes No Cancer/leukemia* Yes No Diabetes/Endocrine/Gland disease/Autoimmune* Yes No Headaches/Migraines* Yes No Overweight/Obesity* Yes No Skin problem (acne, eczema, etc.)* Yes No Mental health issues* Yes No Seizures* Yes No Heart disease* Yes No Hypertension* Yes No Substance use* Yes No Tobacco use* Yes No List any other problems 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 student ever had counseling services? Yes No If Yes,* With CFA Other when/with whom?* If you are interested in mental health services with Child & Family Agency, please call us at 860-437-4550.Has the patient ever had any of the following: Family changes School issues Social stresses Anxiety/panic attacks Anger issues ADHD/Attention issues Depression Recent loss 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. Annual Wellness Screening visits may be completed for healthy lifestyle assessment. Parents/guardians will be notified before screening visits. 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 understand that SBHC 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 School-Based Health Center of any changes to medical information. Age-appropriate, annual risk assessment screenings are completed with students enrolled in the school-based health center as part of best-practices in pediatric care. We offer an "opt-out" of this initiative for universal screenings, if indicated by the parent/guardian in the annual enrollment. Opt out Signature of Parent/Legal Guardian/Personal Representative (or Student if over 18 years old):* Print Name First Last 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.
