"*" indicates required fields Step 1 of 6 16% All information on this registration must be dated and signed before your child can receive services from the School Based Health Centers (SBHC) at Child and Family Agency of Southeastern Connecticut, Inc. (CFA). If a student is 18 or older, they may sign their own permission form. Race & ethnicity information is required by the State and will be used for statistical purposes only.STUDENT INFORMATIONFull legal name (of person who will receive services)* First Last Date of Birth* MM slash DD slash YYYY Student Grade* School that Person Receiving Services Attends (check box next to school):* Bennie Dover Jackson Middle School (New London) Catherine Kolnaski STEAM Magnet School (Groton) C.B. Jennings International Elementary Magnet School (New London) Dr. Charles G. Barnum School (Groton) Ella T. Grasso Technical School (Groton) Fitch High School (Groton) The Friendship School (Waterford) Gales Ferry School/Juliet W. Long School (Gales Ferry/Ledyard) Gallup Hill School (Ledyard) Groton Middle School (Groton) Harbor Elementary School (New London) Ledyard High School (Ledyard) Ledyard Middle School (Gales Ferry/Ledyard) Mystic River Magnet School (Groton) Nathan Hale Arts Magnet School (New London) New London High School (New London) Northeast Academy (Groton) Regional Multicultural Magnet School (New London) Stonington High School (Pawcatuck) Stonington Middle School (Stonington) Thames River Magnet School (Groton) West Vine Elementary School (Pawcatuck) Winthrop STEM Magnet Elementary School (New London) 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 Ethnicity* Hispanic Non-Hispanic Gender Identity Male Female Transgender Male Transgender Female Non-binary Other/Prefer not to Answer Language Spoken at home:* Race* Unknown American Indian Pacific Islander Alaskan Native Black Asian White Other STUDENT’S PRIMARY CARE PROVIDERThe SBHC does not replace your regular community primary care provider. If you do not have a primary care provider, the SBHC will assist you in a referral to a primary care medical home. Student's Primary Care Provider's Name (if none, please write “none”)* Student's Dentist's Name (if none, please write “none”)* MEDICAL HISTORYDate of Last Physical Exam MM slash DD slash YYYY Does the client have any medical and/or behavioral health condition(s)?* Yes No If yes, please list here* Does the client take any medications (including over the counter)?* Yes No If yes, please list here* Does the client have any allergies?* Yes No If yes, please list here (foods, medications, latex, etc.)* What do the allergic reaction(s) look like?* Does the patient have an Epi-Pen (or similar prescription) at school?* Has the client ever been hospitalized overnight?* Yes No Has the client had any surgery in the past?* Yes No AGREEMENT TO RECEIVE SERVICES* I am the legal guardian of a minor, who is receiving services. I have the authority to make decisions about treatment. I am receiving services and I am over 18. I hereby agree to engage and participate in treatment. SELF/PARENT/LEGAL GUARDIAN INFORMATIONName* First Last Relationship to Student* Parent Legal guardian Define* 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 Secondary Emergency Contact First Last Emergency Contact Phone COMMUNICATION AGREEMENTI agree to communications regarding care in the following forms (check all that apply)* Home phone (enter number if clicked) Cell phone (enter number if clicked) Work phone (enter number if clicked) Text messages can be left Voicemails can be left Home Phone*Cell Phone*Work Phone*Parent/Guardian Email Address* Parent/Guardian Email Address Parent/Guardian Phone Number*Parent/Guardian Phone Number Student's Cell PhoneEmail Address* Student's Email Address (if over 12 years) INSURANCE INFORMATIONAll insurance will be billed at the time of the visit. There are no out-of-pocket costs for medical services rendered in school. No one will be refused services due to the inability to pay. Please provide a copy of the insurance card. If your child does not have insurance, please call 1-877-CT-HUSKY.Does the student have Medicaid/HUSKY Insurance? If yes, please fill out the information below.* Yes No Medicaid #* Child’s Name on card* Does the student have Private/Commercial Insurance? If yes, please fill out information below.* Yes No Policy Holder Name* First Last Policy Holder Date of Birth* MM slash DD slash YYYY Name of Medical Insurance* Member ID #* Group Number Primary Insurance Phone (on back of card)Policy Holder’s Employer 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 Is there secondary insurance?* Yes No Secondary Policy Holder Name* First Last Secondary Policy Holder Date of Birth* MM slash DD slash YYYY Name of Secondary Insurance* Secondary Member ID #* Secondary Group Number 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 Secondary Insurance Phone (on back of card)* ACKNOWLEDGEMENT AND CONSENTBy signing below, I understand and acknowledge I have read and understand this consent: I give permission for my child/self (>18 years old) to obtain routine health services at the School-Based Health Center. 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 of Southeastern Connecticut, Inc. (CFA) 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 CFA to exchange as needed information with the client’s primary care 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 the client’s care. 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 client’s health. I will notify the SBHC of any changes. Age-appropriate, annual risk assessment screenings are completed with students enrolled in the SBHC as part of best-practices in pediatric care. We offer an "opt-out" of this initiative for universal screenings, if indicated by the student/parent/legal guardian in the annual enrollment. Opt out Agency Grievance ProceduresA copy of the Grievance Procedure is available upon request and online.*Click here to review the Grievance Procedures I acknowledge CFA’s Grievance Procedures and where to find them. 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. 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.Student's Name* First Last Student's Date of Birth* 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?* Yes No Additionally, sensitive protected health information (PHI) 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?* 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 Southeastern CT, Inc. of the named recipient in writing. Electronic signature of person authorizing health information exchange* Relationship to Student (If <18 years of age): Today's Date* MM slash DD slash YYYY
