"*" indicates required fields Annual Update to SBHC RegistrationSTUDENT INFORMATIONFull legal name (of person who will receive services)* First Last Date of Birth* MM slash DD slash YYYY School Student Attends* Grade* If any of the following information has changed in the last year, please complete the following fieldsPARENT/GUARDIAN INFORMATIONName* First Last Relationship to Student* 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 I agree that voicemail messages can be left for me on (check all that apply)* Home phone Cell phone Work phone Home Phone*Cell Phone*Work 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”):* Any updated medical or surgicial information:*Any updated medication(s):*Any new allergies:*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 cardACKNOWLEDGEMENT 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.
