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School-Based Health Care
A Program of Community Health Center, Inc.
PHYSICAL FORM
Questions or concerns? Call (475) 231-6978

Version en Espa�ol

SBHC Services

School-Based Health Care (SBHC) partners with your school to offer your child
(or yourself, if you are 18 years or older) the services listed below.

By checking the box below, you are opting in to accessible, convenient care during school hours.
If you have previously enrolled with us and are looking to enroll in any additional services,
please check the boxes for all services you wish to be enrolled in.

This form is only consenting to receive medical services with the School-Based Health Center.
If your school offers behavioral health and/or dental services you will need to complete
a new enrollment form at www.sbhc1.com to enroll in any or all services offered at your school.

Authorization Related to Health & Education Information:

By checking below, I hereby authorize Community Health Center, Inc. (CHCI) and the School to exchange health (including behavioral health, substance use disorder, HIV/AIDS, reproductive health, gender affirming care) and education records, if applicable, for the purpose of providing care and treatment to my child/myself. I further authorize CHCI to disclose any applicable physical exam and immunization information required by law to School. I understand that CHCI may need access to student schedules, included but not limited to PowerSchool. I understand that health records received and maintained by School may become education records protected under the Family Education Rights & Privacy Act (FERPA) and may no longer be protected by the Health Information Portability and Accountability Act (HIPAA).

I give my child (or myself, if I am 18 years or older) permission to obtain the services selected below while enrolled in a school in which CHCI provides services (School) or until I revoke permission. I understand that I am giving consent for routine treatment or services that are considered necessary or advisable for my child/me. I understand that I have the right to refuse interventions, treatment, care, services, tests, or medications for my child/myself to the extent the law allows. I understand the care my child/I will receive may include voluntary tests (including HIV/AIDS), medications, injections, etc., that are based on established medical criteria, but not free of risk and that I will be advised of any such risks prior to me/my child receiving such care.

I understand that health professions trainees and students may participate in my child s/my care under the supervision of CHCI staff. If my child/I receives student support services under an IEP, 504 or other education plan at the school, I consent to the support staff being present for any school-based health service (including dental services) when deemed necessary or appropriate by the healthcare provider.

Medical Service

Yes

Services include but are not limited to physicals, immunizations, treatment of minor injuries and illness, and referrals to specialists. The School-Based provider does not replace your child's primary care provider. Checking the box offers your child medical care for a range of needs during school hours.

Would you like your child to receive their flu vaccine with a School Based Health Center staff?

Yes or No?

Yes
No
None of the above

Patient (Student) Information

Patient First Name *

Patient Middle Initial

Patient Last Name *

Grade *

Social Security #

Month of Birth *

Date of Birth *

Year of Birth *

DOB

ADDRESS:
Street 1 *

Street 2

City *

State *

Zip Code *

Patient Primary Language *

Language Other

Sex assigned at birth *

Race and/or Ethnicity *

Don't see your Ethnicity? Enter it here:

American Indian or Alaska Native Ethnicity

Asian Ethnicity

Black or African Ethnicity

Hispanic or Latino Ethnicity

Middle Eastern or African Ethnicity

Native Hawaiian or Pacific Ethnicity

White Ethnicity

Patient's Cell Phone

Patient's Email

Primary Care Provider's Name

Primary Care Provider's Phone

Dental Provider's Name

Dental Provider's Phone

Parent/Legal Guardian Information

Parent/Legal Guardian First Name *

Parent Middle Initial

Parent/Legal Guardian Last Name *

Social Security # (Parent/Guardian)

Relationship to Patient *

Same Address as Child?

Parent/Guardian Street 1 *

Parent/Guardian Street 2

Parent/Guardian City *

Parent/Guardian State *

Parent/Guardian Zip *

Parent/Guardian Month of Birth *

Parent/Guardian Date of Birth *

Parent/Guardian Year of Birth *

Parent/Guardian DOB

What Phone type is Parent/Guardian Primary Phone? *

Parent/Guardian Primary Phone Number

Parent Cell Confirm

Parent Cell Validator

Please enter a valid mobile phone number below

Parent/Guardian Email

Parent Email Confirm

Parent Email Validator

Please enter your email address

Emergency Contact Information

Check to copy from Parent/Guardian

First Name *

Middle Initial

Last Name *

Relationship to Patient *

What Phone type is Emergency contact primary Phone? *

What is your preferred contact phone number *

Emergency Contact Phone Confirm

EC Phone Validator

Please enter a valid mobile phone number below

Emergency Contact Email Address

EC Email Confirm

EC Email Validiator

Please enter your email address

Insurance Information

Please refer to the Financial Obligations below for more information.
All School-Based services are billed to insurances that are provided below.
Please provide insurance information for the patient (student) you are enrolling in services.

By enrolling in the services selected above, I am aware that I am responsible for any deductible or non-covered services provided.

Our Access to Care team is available to assist those who are uninsured or underinsured. Text �help� to (860) 560-1398 for assistance.

Check all insurance types that apply: *

Medicaid/Husky

Medicaid/Husky Insurance ID #:

Policy Holder Name (as it appears on insurance card):

Medical Insurance

Private/Commercial Insurance Company Name:

Private Insurance ID #:

Insurance Company Address (on back of card):

Policy Holder Name (as it appears on insurance card):

Policy Holder Date of Birth (MM/DD/YYYY):

Policy Holder's Relationship to Patient:

Insurance Card

Please Attach Images of Both the Front & Back of your Insurance Card

Front of Card

Back of Card

Do you have additional insurance?

Secondary Insurance

Secondary Insurance Type 2

Secondary Insurance No

Secondary Group No

Secondary Policy Holder First

Secondary Policy Holder's M.I.

Secondary Policy Holder Last

Secondary Policy Holder Birth Date

Secondary Policy Holder Birth Month

Secondary Policy Holder Birth Year

Secondary Policy Holder DOB

Secondary Front

Secondary Back

Patient (Student) Medical History

Please contact CHCI with any changes to this medical history. For Dental, this medical history will need to be updated every four years.

Does the patient take any medications? (including inhalers?)

Please Explain:

Has the patient had any serious injuries?

Please Explain:

Does the patient have a birth or heart defect or a history of a heart problem or surgery?

Please Explain:

Has the patient ever been hospitalized overnight?

Please Explain:

Has the patient had any surgeries in the past?

Please Explain:

Has the patient had any shunts placed or has an indwelling catheter?

Please Explain:

Is/was the patient a teen parent?

Is the patient pregnant or possibly pregnant?

Pregnant Due Date

Is the patient currently nursing?

Is premedication with antibiotics needed prior to dental procedures?

Please Explain:

Does the patient smoke or chew tobacco?

CONDITIONS:

Does the patient have or have they had any of these conditions?

Anemia/blood disorders

Asthma

Autism

Bladder or Kidney Infections

Cancer/Leukima

COVID 19

Diabetes

Eating Issues

Endocrine/Gland/
Autoimmune Disease

Headaches/Migranes

Hepatitis or Liver Disease

Learning/Developmental Issues

Mononucleosis

Overweight/Obese

Pneumonia

Rheumatic Fever, Heart Disease, Murmur

Scoliosis

Seizures

Thyroid Disease

Tuberculosis

Ulcer/digestive Problems

Any Mental Health Issues

Any birth or congenital defects

Any problems with teeth

Any teeth causing pain?

Any bleeding when brushing or flossing

Dental cleaning within last 6 months

Other

ALLERGIES

Is the Patient allergic to?

Food Allergies

Food Allergies Explained

Medication Allergies

Medication Allergies Explained

Local Anesthetics or Latex

Local Anesthetics explained

Does the patient have an Epi-Pen at School?

Epi-Pen explained

Other Allergies

Screening for Flu Vaccine

The following questions will help us to know if your child can get the Influenza Vaccine.

A.If you answer �NO� to all four of the following questions, your child can probably get the influenza vaccine. If you answer �YES� to one or more of the following four questions, your child may be able to get the Influenza vaccine but we may contact you to discuss your options.

Does your child have a serious allergy to eggs?

Does your child have any other serious allergies?

Has your child ever had a serious reaction to a previous dose of flu vaccine?

Has your child ever had Guillain-Barr� Syndrome (a type of temporary severe muscle weakness) within 6 weeks after
receiving a flu vaccine?

Has your child gotten vaccinated with any vaccine (not just flu) within the past 30 days?

Does your child have any of the following: asthma, diabetes (or other type of metabolic disease), or disease of the lungs,
heart, kidneys, liver, nerves, or blood?

Is your child on long-term aspirin or aspirin-containing therapy (for example, does your child take aspirin every day)?

Does your child have a weak immune system (for example, from HIV, cancer, or medications such as steroids or those
used to treat cancer)?

Is your child pregnant?

Does your child have close contact with a person who needs care in a protected environment (for example, someone who
has recently had a bone marrow transplant)?

Flu Consent

By checking this box and signing my name below, I GIVE CONSENT to School Based Health Center and its staff For my child named at the top of this form to be vaccinated with this vaccine.

Type your / parent/guardian name here to sign

Date of Signature

Notice:

To be a CHC Patient, you must read the Rights and Responsiblilities.

Additional Consents and Policies

This Additional Consents and Policies Form is part of the School-Based Health Care Enrollment Form. In this document, if I am consenting for my child, I understand that 'me' 'my' or 'I' refers to my child.

Use and Disclosure of Information

I authorize CHCI to use and disclose my health information for the following purposes:
(1) to provide for, arrange or coordinate health care treatment;
(2) to maintain her/his health information in an electronic health record system and to use secure technology to improve healthcare delivery;
(3) to enable CHCI to obtain payment for the services it provides to me; and
(4) to permit CHCI to carry out ordinary health care and business operations such as quality assurance, service planning and general administration.

I am aware that this authorization to use and disclose information may include information regarding:
(1) HIV or AIDS;
(2) alcohol or drug treatment;
(3) psychiatric or behavioral health;
(4) sexually transmitted diseases;
(5) family planning, pregnancy and abortion. I am aware and agree that CHCI may share information with my child s other medical providers for medical treatment or with a third party for financial payment through electronic means. I authorize CHCI to request and use my prescription medication history from other health care providers and/or third-party pharmacy benefit payers for treatment purposes. This consent form will remain in effect until the day I revoke consent. To revoke consent at any time, I will speak to a CHCI Patient Services Associate.

Assignment of Benefits

I assign to CHCI all benefits to which I child may be entitled from Medicare, Medicaid, other government agencies, insurance carriers or other third parties who may be financially liable for the medical care and treatment provided by CHCI. I authorize the release of information required by the insurance company for billing purposes and realize that proof of insurance coverage needs to be provided for CHCI to file an insurance claim on my behalf. I agree that any benefits paid by my insurance carrier will be paid to CHCI. I agree to notify CHCI immediately of any changes in my insurance.

Financial Obligations

I agree that, except as may be limited by law or CHCI s agreements with third party payers, in the event of non-payment by my insurance for which I have provided an assignment of benefits, I am obligated to pay all amounts due for services provided at CHCI locations in accordance with the rates and terms of CHCI in effect on the date of service. I also agree that I am responsible for any applicable copayments, coinsurance or deductibles. I understand should I fail to provide any requested information to my insurance company or CHCI, CHCI reserves the right to bill me for services at the full fee. I understand that failure to pay will result in a full review, including a review of all options available to me such as a payment plan or fee reduction, and, in some instances, may result in termination from the practice. I understand that I have access to CHCI s payment plan, fee reduction and sliding fee scale discount program for charges based on my income, and I agree to notify CHCI immediately of any changes in my income. I understand that I should speak to a CHCI Patient Services Associate if I have questions about the sliding fee scale discount program.

Contact Release

CHCI routinely contacts patients by phone, email, text message and/or mail to remind them about appointments; notify them of available test results and recommended routine exams, tests and vaccinations; inquire about bills and insurance; and notify them of other CHCI programs and services. By providing CHCI with a cell phone number, I acknowledge that I consent to receiving the above types of text messages. I understand that I can change my communication preferences at any time by speaking with a CHCI Patient Services Associate.

Health Information Exchange

A health information exchange (HIE) allows CHCI to share clinical information through an electronic platform with other doctors, nurses, hospitals, healthcare facilities, insurers and government entities when allowed by law. HIEs provide real-time access to health information, which could prove useful in an emergency and generally improves coordination and quality of care. CHCI participates in the state mandated HIE, known as CONNIE, and with the national HIEs associated with its electronic health record system.

State Mandated HIE

Connecticut requires all healthcare providers to participate in the state's health information exchange (CONNIE). By state law, all patients are automatically included in CONNIE. This means that unless a patient opts-out of having that patient's information shared through the CONNIE, patient information will be shared through CONNIE with other treating providers, state agencies and insurers as permitted by law. The only way to opt-out of this HIE is through CONNIE directly. I understand that I can opt-out of CONNIE by visiting connect.conniect.org or by calling 866-987-5514.

Sensitive information including HIV/AIDS, behavioral health and substance use disorder information (Sensitive Information) will not be shared with CONNIE without my consent. I understand that I can consent to sharing my Sensitive Information by checking the box below. I will leave the box empty if I do not wish to participate.

HIEs Associated with the Electronic Health Record System

CHCI s electronic health record system (EHR) participates in national HIEs (EHR HIEs). These EHR HIEs assist in providing the best possible care by allowing providers outside of CHCI who also use the same EHR to see patients clinical information when relevant.

By checking the box below and agreeing to participate in the EHR HIEs, I understand that healthcare providers and authorized personnel that participate in the EHR HIEs will be able to access my health information more effectively and accurately. I understand that shared information may include sensitive information such as HIV/AIDS, behavioral health and substance use disorder information (Sensitive Information).

I understand that if I want to participate in the EHR HIEs and to have CHCI share my information, including Sensitive Information, I will check the box provided below. I will leave the box empty if I do not wish to participate.

Consent to Share with HIEs

If you wish for CHCI to share your child s Sensitive Information with CONNIE and if you wish for CHCI to share your child s information including Sensitive Information with the EHR HIEs, please indicate your consent by checking the box below. If you leave the box blank or unchecked, CHCI will not share Sensitive Information with CONNIE or any information with the EHR HIEs.

I agree to allow CHCI to share my Sensitive Information with CONNIE and my child s information, including Sensitive
Information, with the EHR HIEs.

Patient Rights & Responsibilities

I understand that CHCI prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.

As a patient, I have the right to:

* Be treated with dignity and respect by all staff and providers;

* Have treatment and other health information kept private except in an emergency or as otherwise provided for by law;

* Be free from unlawful discrimination;

* Receive services from a provider who has met the qualifications of training and experience required by state law;

* Be informed of the cost of healthcare services before receiving the services;

* Access my records in accordance with the law;

* Take part in treatment planning;

* Refuse any service or treatment unless mandated by a court;

* Report complaints to CHCI, my provider, and/or to the Department of Public Health;

* Terminate the provider-patient relationship at any time;

* Receive appropriate referrals to other providers whenever requested, as well as in the case of a patient termination.

The following are patient responsibilities:

* Treat CHCI's diverse staff and providers as well as other patients and visitors with dignity and respect;

* Do not engage in inappropriate, aggressive, harassing, violent, abusive or threatening behavior (e.g., swearing, yelling, name-calling, physical violence, damage to property, threats of violence, etc.);

* Follow CHCI policies and procedures and staff instructions while at CHCI;

* Raise any concerns/questions with the provider regarding my treatment or the services I receive;

* Follow the treatment plan on which my provider and I agreed and let the provider know if the treatment plan no longer works for me;

* Keep my appointments and arrive on time;

* Contact CHCI as soon as possible if I need to cancel a visit;

* Ensure that minors are accompanied to visits (except SBHC clinics);

* Pay my co-pay, co-insurance or any amount due at the time of the visit;

* Notify CHCI of any change in income if I participate in the sliding fee scale discount program.

I have reviewed & agree to the CHC Notices of Privacy Practices *

I have reviewed & agree to the CHC Patient Rights and Responsibilities Document *

Consent for Treatment

By checking this box & signing my name below I am acknowledging that I have read and understand the above information.
If not patient or parent, proof of legal authority must be provided. *

Type the parent/guardian's name to sign *

Signature Date *

Submit

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Ethnicity = White

Ethnicity = American Indian or Alaska Native

Ethnicity = Black or African American

Ethnicity = Hispanic or Latino

Ethnicity = Middle Eastern or North African

Ethnicity = Native Hawaiian or Pacific Islander

Eating Issues Combined

Dental Insurance Type

Dental Insurance = Medicad/Husky

Dental Insurance = Private/Commercial

Behavioral Health Services Requested

Medical Services Requested

Dental Services Requested

Parent Email Confirm Message

Phone Confirm Message

EC Email Confirm Message

EC Phone Confirm Message

Medical and Dental Services Declined

Medical and Dental Services not Available

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