QACPS Staff Enrollment Form

School Based Health Centers

QACPS Staff Enrollment Information
Please review the following information before beginning the enrollment form.

School Based Health & Dental Centers are a partnership between Choptank Community Health, your school district, and (if applicable) the county health department. This program allows staff to receive medical care right at school. Care is coordinated with your primary care provider.

Services available in the School Based Health Centers include:
- Diagnosis and treatment of illness, including referrals
- Referals for behavioral health services
All public school staff in Caroline, Dorchester, Kent, Talbot, and Queen Anne's Counties are eligible to visit ANY school-based health center.

To complete this enrollment form, you will need:
- Your health history, including medications, allergies, and recent surgeries
- Your family health history
- Health insurance information
Note: Depending on your insurance plan, payment will be due at the time of visit for copays, unmet deductibles, and any non-covered services. If you do not have insurance, we offer a sliding fee scale. Patients on the sliding fee scale will be billed based upon their income. All patients are eligible to apply for the sliding fee program even if they have insurance. Finally, the cost associated with lab services will be billed to your insurance. Bills for these tests will come directly from the lab company.

If you have questions about the program, please contact Choptank Community Health System at 410-479-4306 Ext. 1038.

Patient Information
I am a teacher or staff member at:*
Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:*

MonthDayYear
Gender*

MaleFemalePrefer not to respond
Social Security Number:
Race:*
Hispanic / Latino?*

YesNo
Preferred Language:*
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Primary Care Doctor
Name of Doctor:
Doctor's Phone Number:
Please enter a valid phone number.
Primary Dentist
Name of Dentist:
Dentist's Phone Number:
Please enter a valid phone number.
Pharmacy
Name of Pharmacy:
Pharmacy's Phone Number:
Please enter a valid phone number.

Emergency Contact Information
Name of Emergency Contact:*

First NameLast Name
Relationship:*
Preferred Language:
Phone Number #1*
Please enter a valid phone number.
Phone Number #2 (optional)
Please enter a valid phone number.
Name of Second Emergency Contact:

First NameLast Name
Relationship:
Preferred Language:
Phone Number #1
Please enter a valid phone number.
Phone Number #2 (optional)
Please enter a valid phone number.

Health Insurance Information
Do you have health insurance?*

YesNo
NOTE: If you do not have health insurance, you are still eligible to receive service. You may apply for the Sliding Fee program later in this form.

If you have health insurance but do not have your insurance information available at this time, you may provide it at a later date.
Insurance Name:
Policy / Member ID Number:
Group Number:
Subscriber Name:

First NameLast Name
Subscriber Date of Birth:

MonthDayYear
Subscriber's Employer:
Claims Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Sliding Fee Information

If you are not interested in applying for the Sliding Fee, please click "Next" at the bottom of the page. Patients on the sliding fee program can receive discounts that are billed based upon their income. All patients are eligible to apply for the sliding fee program, even if they have insurance.
Would you like to apply for the Sliding Fee?

YesNo
If yes, number of people in your household:
If yes, annual household income (enter number only):

Consent & Signature

By signing below, you agree:
I understand that my signature gives consent for the CCHS School Based Health Center Providers to treat me and to communicate with my primary health care provider. I give CCHS permission to call my home, leave a message regarding healthcare information. CCHS may also mail healthcare information to my home.

I understand that my health information will be used for treatment, payment and health care operations.

I recognize that school directories will be used to obtain information left blank on the enrollment form.

My immunization record may be shared between the School Nurse and the School Based Health Center. For the purposes of care coordination and case management, School Clinical Staff will have access to the SBHC health records and School Clinical Staff shall share health information with the SBHC staff. School Clinical Staff are required to treat the information in the SBHC health record as confidential and comply with the HIPAA Privacy Rule and the FERPA Act.

I understand that services provided to me will be billed to my insurance carrier or Medical Assistance. I may receive a bill from CCHS for copays and/or deductibles.

I understand that my signature indicates that I have had the opportunity to receive and review the Choptank Community Health’s Notice of Privacy Practices. We participate in the CRISP health information exchange ("HIE") to share your medical records with your other health care providers and for other limited reasons. You have rights to limit how your medical information is shared. We encourage you to read our Notice of Privacy Practices and find more information about CRISP medical record sharing policies at crisphealth.org.

If I do not have insurance, visit costs will be billed for the full cost of services or at a reduced rate with a sliding fee discount, if applicable. I will be offered a Sliding Fee Application whether or not I have health/dental insurance.

Our privacy forms can be found online at choptankhealth.org/formsinformation.
Signature*

Clear
Should be Empty:

School Based Health Centers

Patient Information

Primary Care Doctor

Primary Dentist

Pharmacy

Emergency Contact Information

Health Insurance Information

Sliding Fee Information

Patient's Health History

Family History

Consent & Signature