School Based Health Center Registration Form

STUDENT INFORMATION
Full legal name (of person who will receive services)*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City 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 Number
Student's Dentist's Name*
Student's Dentist's Phone*
Has your child seen this dentist/group for 1+ years?*
- Yes
- No

INSURANCE INFORMATION
Coverage*
- Husky / Medicaid
- Commercial / Private Insurance
- No Insurance
Primary Medical Insurance*
Member ID #*
SS# can be used if Husky ID is unknown
Group Number
Insurance Phone #*
On back of card
Policy Holder Date of Birth*
Date Format: MM slash DD slash YYYY
Secondary Insurance
Member ID #*
SS# can be used for Husky if ID unknown
Group Number
Insurance Phone #
On back of card
Policy Holder Name
First Last
Policy Holder Date of Birth
Date Format: MM slash DD slash YYYY
Secondary Insurance
Member ID #
Group Number
Insurance Phone #
On back of card
Policy Holder Name
First Last
Policy Holder Date of Birth
Date Format: MM slash DD slash YYYY

PARENT/GUARDIAN INFORMATION
Name*
First Last
Relationship to Student*
Date of Birth
Date Format: MM slash DD slash YYYY
Address
If different from above

Street Address Address Line 2 City 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 Phone
Parent/Guardian Email Address*
Enter Email Confirm Email
Student Cell Phone
Student Email Address

EMERGENCY CONTACT
Emergency Contact (1) Name
First Last
Relationship (1) to Student
Emergency Contact (1) Phone Number
Emergency Contact (2) Name
First Last
Relationship (2) to Student
Emergency Contact (2) Phone

ALLERGIES
Any 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

ACKNOWLEDGEMENT AND CONSENT
By 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*
Date Format: 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.

School Based Health Center Registration Form

SBHC Registration (rev 20200720)

Step 1 of 9

STUDENT INFORMATION

INSURANCE INFORMATION

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT

MEDICAL HISTORY

PAST AND PRESENT PROBLEMS

FAMILY HISTORY of any of the following:

ALLERGIES

BEHAVIORAL HEALTH

ACKNOWLEDGEMENT AND CONSENT